Pathological Demand Avoidance (PDA) is recognised as a profile within the autism spectrum, characterised by extreme demand avoidance or a pervasive drive for autonomy. Some researchers debate whether PDA should be classified as part of autism spectrum disorder or even if PDA is better explained as part of attention deficit hyperactivity disorder (ADHD).

There is a general lack of consensus among professionals around diagnostic criteria. PDA is not often well defined making it difficult to operationalise. This in turn makes it challenging to distinguish PDA from ASD, ADHD, oppositional defiance disorder (ODD), obsessive compulsive disorder (OCD) or conduct disorder (usually diagnosed in later teen years).

Including demand-avoidance traits in comprehensive assessments can impact the understanding and classification of Autism spectrum disorders, particularly for those with an autism diagnosis.

PDA is not included in the diagnostic and statistical manual, highlighting the challenges in establishing it as a distinct diagnosis.

Some current studies lack appropriate comparison groups, making it challenging to determine whether the behaviours are specific to PDA or another diagnosis such as ASD, ADHD, OCD, or ODD.

Occasionally, determining whether a person has PDA depends on trial and error and ruling out other diagnostic factors.

PDA is often described as a person who continuously seeks to avoid demands, this can through retreating (running away), not responding or even physical violence. However, through a PDA lens this behaviour is not described as pathological or a decision to act in an oppositional way but is anxiety towards demands or requests.

PDA can resemble Oppositional Defiant Disorder (ODD), and due to its very similar behavioural presentation. This may be problematic as those with PDA typically do not respond well to traditional behavioural strategies. Strategies which focus on compliance may exacerbate their symptoms and negatively impact their quality of life.

Understanding and Supporting Unique Needs

Pathological Demand Avoidance (PDA) is a complex and multifaceted condition that is often misunderstood.

It is essential to approach individuals with PDA with empathy and understanding, recognising that their behaviours are not a result of being “difficult” or “oppositional,” but rather a coping mechanism to deal with the overwhelming anxiety and stress that comes with everyday demands.

People with PDA experience a pervasive need to avoid demands, which can be anything from simple requests to more significant expectations. This extreme demand avoidance is not a choice but a response to the intense anxiety they feel when faced with these demands. Understanding this can help in creating supportive environments that reduce anxiety and promote positive interactions.

Core Characteristics of PDA

Individuals with PDA often exhibit a range of core characteristics, including:

  • Persistent and Marked Resistance to Demands: This can manifest in various ways, such as refusal to comply, tantrums, or meltdowns. The resistance is not just to significant demands but also to ordinary demands that others might find trivial.
  • Need for Control and Autonomy: This need can lead to rigid and inflexible behaviour. Individuals with PDA often feel a strong need to be in control of their environment and interactions, which can make them appear stubborn or uncooperative.
  • Sensitivity to Stress and Anxiety: They are overly sensitive to stress and anxiety, which can trigger panic attacks or shutdowns. This heightened sensitivity means that even minor changes or demands can be overwhelming.
  • Social Interaction Needs and Challenges: While they may seek social interaction, they often struggle with initiating or maintaining relationships due to difficulties with social cues and boundaries. This can lead to misunderstandings and social isolation.
  • Use of Social Strategies to Avoid Demands: They often use social strategies to avoid demands, such as making excuses, distracting, or diverting attention. These tactics are not manipulative but are ways to manage their anxiety and avoid stress.

Key Differences Between Autism and Autism with a PDA Profile

Here’s how individuals with autism and those with an autism PDA profile differ:

  1. Resistance to Everyday Demands: People with PDA are more likely to resist and avoid routine requests and tasks. They may have higher sensory needs and often seek out sensory stimulation, novelty, and high-dopamine activities, such as screen time, to regulate themselves. Autism researchers play a crucial role in understanding these differences and the unique profiles of autism and PDA.
  2. Avoidance Tactics: They often use various methods to avoid demands, like distraction, making excuses, delaying, escaping into fantasy, or creating noise to drown out the request. Additionally, those with PDA may disengage from therapists or clinicians once they understand what the professional is trying to achieve. As a result, therapy often needs to be led by the person with PDA.
  3. Social Interaction: They may seem sociable but often have gaps in their understanding of social cues. They struggle socially due to their insistence on autonomy and their difficulty in allowing others to take the lead, which may be perceived as overly controlling behaviour. This insistence on autonomy often leads to a rejection of traditional hierarchical structures, including those involving authority figures like parents or teachers.
  4. Mood Swings and Impulsivity: They tend to experience more mood swings and act impulsively. They may rapidly shift from a regulated state to a fight-or-flight response as they internalise threats in their environment at a higher rate than those without PDA. For example, expectations from others or societal expectations can trigger this response. When continuously stressed, the brain and body struggle to regulate, leading to a shutdown or “freeze” response.
  5. Role Play: They are often comfortable with pretending and role-playing, but this typically needs to be led by them. When those with PDA detect that the intention of play is to teach them something or as part of therapy, they may disengage.
  6. Intense Focus: They might have strong interests or fixations, whether positive or negative, and can focus intensely on other people. Those with PDA can become highly fixated on their special interests, which they often gravitate toward, becoming frustrated if they are denied access or cannot access these interests when they wish to.
  7. High Masking: Those with PDA are often observed to be high-masking and can appear well-behaved in settings such as school or a relative’s house, only to exhibit challenging behaviour at home. This can be highly confusing, especially for families. However, if the person reaches a stage of burnout, these behaviours may start occurring in all settings

Empowering Interventions for PDA

Our LiveBig Practitioners can help support clients on the autism spectrum with a PDA profile by tailoring to their individual needs, taking into consideration their age, communication abilities and specific challenges. The PDA Society plays a crucial role in providing support and recognition for individuals with pathological demand avoidance syndrome (PDA). Here are some common evidenced based interventions:

  • Psychologists: A psychologist will use therapies such as Cognitive Behavioural Therapy to help manage anxiety, negative thinking and demand avoidance.
  • Occupational Therapy (OT): An OT can work on sensory processing issues or help individuals develop coping strategies for managing overwhelm and stress.
  • Speech and Language Therapy: This can help with communication challenges, especially in cases where language is a barrier to expressing needs or understanding social cues.
  • Positive Behaviour Support (PBS): A PBS Practitioner can support Participants as well as their in-home and external supports to implement specific behavioural interventions and strategies tailored to their PDA. By recognising the underlying functions of the Participant’s behaviours that align with pathological demand avoidance syndrome (i.e., avoid/escape), strategies are then implemented to avoid further escalation in behaviours of concern.

Key Takeaways

In understanding Pathological Demand Avoidance (PDA) within the autism spectrum, several key points emerge:

  • Unique Profile within Autism Spectrum: PDA is recognised as a distinct profile characterised by extreme demand avoidance and a pervasive drive for autonomy. It is often debated if PDA is classified as part of autism spectrum disorder or if it is better explained as part of attention deficit hyperactivity disorder (ADHD).
  • Demand Avoidance as a Coping Mechanism: Individuals with PDA exhibit marked demand avoidance not as a choice, but as a response to intense anxiety triggered by everyday demands.
  • Core Characteristics: These include persistent resistance to demands, a need for control and autonomy, sensitivity to stress and anxiety, challenges in social interaction, and the use of social strategies to avoid demands.
  • Impact on Daily Life: Extreme demand avoidance affects relationships, mental health, and daily routines, often leading to increased anxiety, social isolation, and meltdowns.
  • Interventions and Support: Tailored interventions, such as cognitive behavioural therapy and positive behaviour support, are crucial in managing PDA behaviours and promoting positive outcomes.

Embracing the Challenge

Pathological Demand Avoidance (PDA) is a complex and multifaceted condition that requires understanding, empathy, and support. By recognising the core characteristics and demand avoidance strategies of individuals with PDA, we can work towards creating a more inclusive and supportive environment that acknowledges their needs and promotes their well-being.

It is essential to approach individuals with PDA with patience, compassion, and flexibility, and to work collaboratively with them to develop strategies that promote their autonomy, control, and social interaction.

If you would like to find out more or talk to one of our experienced clinicians, contact us today.