Pathological Demand Avoidance (PDA) in Autism
People with demand avoidant behavior don't always have autism
Medically reviewed by Jonathan B. Jassey, DO
Pathological demand avoidance (PDA) refers to a profile of behaviors in which a person's anxiety causes them to avoid everyday demands at an extreme level. PDA is most commonly associated with autism but may also be related to attention deficit hyperactivity disorder (ADHD), epilepsy, and more.
There is controversy within the medical, autism, and neurodiverse communities about the validity of PDA. Pathological demand avoidance is not diagnosable because it is not listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) or the International Classification of Diseases, Tenth Revision (ICD-10).
In this article, learn more about pathological demand avoidance in autism, how to cope with these behaviors, and the controversy surrounding this term.
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Neurodivergent vs. Neurotypical
Neurodiversity is the concept that there is a natural spectrum of differences in each human's brain and that these differences are worth celebrating rather than pathologizing. Neurotypical people have a "normal" brain and behave in ways society expects. In contrast, a neurodivergent individual has brain differences that lead them to behave in ways society doesn't always expect. Anyone who is diagnosed with autism is neurodivergent.
Pathological Demand Avoidance (PDA): A Trait of Autism?
British psychologist Elizabeth Newson coined the term pathological demand avoidance (PDA) in the 1980s. Newson was working in a mental health clinic with children who had been referred to her because their behavior "reminded" their doctors of autism but didn't quite meet the typical criteria, usually because they were too sociable or imaginative.
Newson noticed a common profile of behaviors across these children, defined by an extreme avoidance of everyday demands coupled with the use of social strategies to aid in their avoidance, which she eventually called "pathological demand avoidance."
The first published mention of PDA was in a 2003 medical journal in which Newson described it as a diagnosis sitting under the umbrella of pervasive developmental disorder. Pervasive developmental disorder is an outdated term that has since been replaced with autism spectrum disorder (ASD) as of the 2013 DSM-5.
Over time, PDA has evolved to being seen as a (relatively uncommon) profile of behaviors within autism. However, it is still not an official diagnosis because it is not recognized by the DSM-5.
Key Features of PDA
In her 2003 article, Newson listed "key features" of PDA that she had observed. Most scientific literature still uses these key features to understand PDA and provide a cohesive definition. You can think of the "key features" as symptoms of PDA, which include:
Avoids and resists ordinary demands to an extreme extent
Uses social strategies as part of this avoidance
Surface sociability but lack of shame, pride, and identity
Mood swings and impulsivity, usually led by a need for control
Comfortable with role play and pretending
Obsessive behavior, often associated with other people
PDA Controversy
Research on pathological demand avoidance is limited, and the term's validity continues to spark debates worldwide.
Supporters of PDA argue that labeling these behaviors offers a pathway to faster treatment and a community of others who have had similar experiences. In the United Kingdom, where the concept of PDA originated, diagnostic tools are in development, and the Autism Education Trust, Department of Education, and National Autistic Society now recognize PDA.
Yet, PDA is still not included within the DSM-5 or ICD-10 and lacks international recognition, meaning there is no universal standard for diagnosis.
Some experts argue that PDA is not a subtype of autism; instead, it is a general behavior profile that could be associated with many different conditions.
There is also an argument that this label pathologizes and punishes self-advocacy among individuals with autism. Whereas, from the perspective of an autistic person, avoidance of demands that elicit extreme anxiety is a perfectly rational response rather than "pathological."
As a result, some autistic scholars have proposed renaming PDA to:
Rational demand avoidance
Extreme demand avoidance
Pervasive drive for autonomy
PDA Outside of Autism
Although PDA is most frequently discussed in the context of autism, it has also been associated with other conditions discussed below.
Ultimately, though, there is a real lack of research on PDA. It is not yet possible to say what conditions PDA is most associated with because PDA has not been thoroughly defined or studied.
ADHD
There are anecdotal reports that PDA is associated with ADHD. One study found evidence to support this connection. However, ADHD is also commonly diagnosed alongside autism, so the exact relationship between these three conditions is unclear.
Epilepsy
Epilepsy is another condition connected to PDA, although evidence is limited to low-quality case studies. In her seminal 2003 paper on PDA, Newson mentioned possible neurological involvement and that she observed co-occurring epilepsy in some children with PDA.
Oppositional Defiant Disorder
PDA has also been associated with oppositional defiant disorder (ODD), a condition diagnosed among children who act irritable, argumentative, and defiant.
However, this likely is either a misdiagnosis or an unhelpful way of conceptualizing PDA behaviors. PDA differs from ODD in that the "defiance" stems from overwhelming anxiety and is not willful.
Effects of PDA, With or Without Autism
A person with PDA will avoid ordinary demands and expectations to an extreme level. They use social strategies—such as negotiation, distraction, manipulation, role play, and refusal—to avoid demands.
Examples of "demands" include:
Expectations
Time limits
Prearranged plans
Transitions
Praise (and the implied expectation of repeating the praised trait or activity)
Questions
Decisions
Bodily demands (such as thirst or hunger)
Uncertainty
Enjoyed activities
PDA Behaviors and Motivation
But why does someone with PDA refuse to brush their teeth, put on clothes, finish their homework, attend an appointment, show up at work, or participate in their favorite hobbies and activities in the first place?
For many people with PDA, the reason comes down to anxiety and control. People with PDA report that demands—however small—can feel like their sense of control and agency is getting ripped away from them.
This results in high anxiety levels, making them feel "frozen" and unable to comply. They may even say something like, "I can't; my legs are frozen," which should be taken literally.
How PDA Feels
For the demanding party, avoidance can seem frustrating, illogical, or vindictive. You may gain empathy for their situation by trying to understand how PDA feels to the person who has it.
For this, it is helpful to hear directly from individuals who identify as having PDA. Below are some ways that people with PDA described their experience to the PDA Society:
“Although I’m acting angry, what I’m feeling is terror, and afterwards, I don’t remember what I’ve done.”
“Demand avoidance makes it sound like I’m avoiding things on purpose, but I literally have no choice in it whatsoever. So I prefer to call it demand anxiety.”
“PDA is like trying to face your phobias every waking moment! "
“I like to describe the experience of being under a demand as similar to having claustrophobia. The anxiety keeps rising steadily until it becomes a non-negotiable, panic-driven need to flee from the source of the demand.”
How to Approach Discipline in Children With PDA
Traditional parenting and discipline strategies that include strict boundaries and contingency-based rewards or punishments are ineffective for children with PDA. Sometimes, these "normal" strategies worsen the child's PDA behaviors.
Remember that a child with PDA has an intense need for control, and their refusal to do what you ask may be based on a paralyzing anxiety that they are losing control rather than defiance toward your requests.
Instead, experts recommend adopting a "low demand, low arousal" approach to parenting and discipline.
Some PDA parenting suggestions include:
Develop boundaries, but grant your child a certain level of autonomy.
Place less importance on complete adherence to your demands and accept any level of adherence.
"Pick your battles" selectively and carefully.
When making a demand, use indirect language, non-verbal cues, novelty, and leading requests with "please"
Use a positive rapport with laughter and humor, playfulness, and incorporate activities you know your child enjoys.
Avoid direct instructions or commands.
Let your child choose activities from a list rather than requesting a single demand so that they feel a sense of agency.
Frame a demand as a "challenge" or game.
Try to approach your child's response with neutral expectations and remain conscientious of their anxiety levels.
Do not praise your child excessively because they may also see this as a demand to rise to your expectations and elicit that praise again in the future.
Use a mutually agreed upon reward system, including giving your child the autonomy to reward themselves.
How to Respond to Adults With PDA
Although much of the existing research on PDA is on children, it's important to remember that these children grow into adults with PDA. Many of the strategies listed above will remain helpful in responding to adults with PDA.
Mindful Skills to Build With PDA
PDA is a lifelong condition, but there are things you can do to learn to cope with PDA behaviors if you match this profile.
Some skills to build with PDA include:
Recognizing what constitutes a demand and how to manage and reframe demands
Learning to recognize your avoidance strategies
Self-acceptance and self-awareness
Understanding "masking" and how this affects you
Sensory regulation
Awareness of personal triggers
The PDA Society has many resources for living, attending work and school, and managing relationships with PDA. They also have case studies and stories written by individuals with PDA.
Attending therapy with a PDA-informed professional, such as acceptance and commitment therapy (ACT), can also help.
Professional Guidance on PDA Disorder
Seeking support for PDA can be challenging because of the controversy and uncertainty surrounding it and because it is not a diagnosable condition included in the DSM-5.
Awareness and requests for PDA diagnosis are growing, particularly in the United Kingdom (where the term originated and most of its research is performed). In the United States, PDA awareness is much lower.
If you suspect that you or someone you care for has PDA, seek help from a PDA-informed clinician, educator, or social services professional. The PDA Society provides guidance and information sheets for professionals who want to learn more about the PDA profile.
More resources on PDA include:
PDA Support Groups (Facebook and in-person)
PDA Books (for both children and adults)
Summary
PDA is a controversial term that refers to a profile of behaviors sometimes seen in individuals with autism. People with PDA avoid demands to an extreme extent and use social strategies like distraction, refusal, role-playing, evasion, and more to help with this avoidance. It is challenging to receive an official diagnosis because it is not an officially recognized condition. However, resources are available to learn more about PDA and coping strategies you can try to manage its associated behaviors.
Read the original article on Verywell Health.
