Discussion of pathological demand avoidance (PDA) and requests for this diagnostic label have increased in the past few years. PDA was initially used to describe children who use “social manipulation” to avoid demands of parents or caregivers. Additional features include a “challenging behavioral profile,” such as resisting everyday demands and requests, a desire to be in control during social interactions, and a tendency to go to “extreme lengths” to avoid and control.
PDA has been conceptualized both as a subtype or behavioral profile of autism spectrum disorder (ASD) and other developmental disorders. Some practitioners argue that PDA is a helpful diagnostic label that can inform treatment approaches. Other practitioners argue that labeling a child with a PDA profile pathologizes behaviors that should be considered reasonable in those with ASD. Moreover, there is concern about the lack of uniformity and stability in PDA characteristics and behaviors. In this article, we aim to highlight characteristics of the PDA profile, as well as the benefits and criticisms of this diagnostic label.
What is PDA?
At some point in childhood, most children will exhibit some kind of oppositional or challenging behavior in an attempt to avoid parental requests or asks. Children with PDA, however, are conceptualized as having an extreme, “anxiety-driven need” to control their environment, as well as the demands and expectations of others. The ASD characteristics of inflexibility and rigid patterns of thinking appear to be intensified in children with PDA. Children with PDA experience significant internal discomfort when they are told what to do or how to behave, which can lead to avoidance. Avoidance can look like making excuses, hyper-focusing on another task, withdrawing, or talking excessively. It can also result in more extreme avoidance if the demand is not removed, such as having a meltdown, deliberately urinating, throwing or threatening to throw items, and more.
The task/behavior may be an ordinary part of daily life (e.g., putting on shoes, getting dressed, sitting down at the table) and something that the child is capable of doing. Completing the task often requires less effort than the level of distress and upset created by avoiding the task. Consequently, demand avoidance in children with PDA can appear illogical or counter-intuitive to an outsider, or even deemed an act of “willful defiance.” Overall, this level of demand avoidance is described as “pathological” because it can lead to severe disruptions in a child’s everyday functioning and require parents/caregivers to go to extreme lengths to manage demands.
Benefits of Labeling the PDA Profile
Some practitioners argue that the diagnostic profile of PDA is helpful for informing treatment approaches and strategies in order to respond effectively to a child’s needs. Treatment strategies that work for children with ASD may not work for children who exhibit PDA behaviors. For example, positive reinforcement and contingent strategies may not work well for children with a PDA profile. Rather than being viewed as a reward, children with PDA may become more distressed because rewards can emphasize adult authority. Consequently, the strategy of contingent rewards may actually increase the likelihood of future avoidance.
A collaborative approach with negotiation is thought to be helpful for children with a PDA profile. This can help the child feel more in control and less anxious. A key recommendation is identifying what motivates the child and building on that. Increasing motivation and encouraging flexibility can help decrease avoidance in children with the PDA profile. For example, if a child is very interested in and motivated by dinosaurs, a parent might say, “Let’s see who can list the most dinosaurs,” while helping the child get dressed.
Criticisms of Labeling the PDA Profile
As previously discussed, children with the PDA profile of ASD exhibit demand avoidance in response to tasks and behaviors that may be an “ordinary part of life.” Research indicates that in general, people with ASD experience and make sense of the world around them very differently (e.g., exhibit more sensory challenges, have more social difficulties) than neurotypical people do. In turn, researchers suggest that because people with ASD experience the world differently, then it is understandable that everyday life tasks result in significant and debilitating anxiety. Consequently, some researchers argue that demand avoidance should not be conceptualized as “pathological,” but rather a reasonable and “rational” reaction to requests.
Moreover, research on PDA has mainly been conducted in Western Europe, with the majority of studies stemming from a set of clinics in the United Kingdom. Despite its increasing popularity, the criteria for PDA remains unclear. The initial study on PDA did not specify how these criteria were developed and it also remains unclear whether these criteria remain stable over time. Consequently, PDA characteristics and behaviors require further study before any definitive answers can be offered.
Summary
Pathological demand avoidance is a behavioral profile associated with ASD. Children who exhibit a PDA profile demonstrate intense avoidant behaviors (e.g., meltdowns, making excuses, throwing objects) when they are asked to complete ordinary, everyday tasks. These avoidant behaviors are thought to be driven by anxiety and rigid patterns of thinking. Understanding the PDA profile can help inform treatment approaches given that children with PDA may not respond well to treatment strategies typically used for children with ASD. However, some researchers argue that PDA should be conceptualized as “rational demand avoidance,” given that everyday life tasks require more mental effort for children with ASD compared to their neurotypical peers. Therefore, their avoidance of tasks that require intense effort and cognitive demand is considered reasonable and rational. Additionally, the characteristics and behaviors for PDA remain unclear. Overall, more research is needed to better understand the PDA profile.
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References
Kildahl, A. N., Helverschou, S. B., Rysstad, A. L., Wigard, E., Hellerud, J. M. A., Ludvigsen, L. B., & Howlin, P. (2021). Pathological demand avoidance in children and adolescents: A systematic review. Autism, 25(8), 2162-2176.
Moore, A. (2020). Pathological demand avoidance: What and who are being pathologised and in whose interests? Global Studies of Childhood, 10(1), 39–52.
Newson, E., Marechal, K. L., & David, C. (2003). Pathological demand avoidance syndrome: A necessary distinction within the pervasive developmental disorders. Arch Dis Child, 88, 595-600.
O’Nions, E., Viding, E., Greven, C. U., Ronald, A., & Happé, F. (2014). Pathological demand avoidance: Exploring the behavioural profile. Autism, 18(5), 538–544.
O’Nions, E., & Eaton, J. (2020). Extreme/‘pathological’ demand avoidance: An overview. Pediatrics and Child Health, 30(12), 411-415.