What is Pathological Demand Avoidance?

Pathological Demand Avoidance Syndrome (PDA) is a term coined by Elizabeth Newson in 2003 to describe a specific pattern of behavior in children within the autism spectrum/profile. These children display an extreme avoidance of everyday demands and requests, which can often be obsessive and cause significant distress in their functioning.

Characteristics of PDA include:

• Obsessive resistance to requests or expectations, often resulting in anger, frustration, or manipulation to avoid compliance.
• Deficits in social communication 
• Use of avoidance strategies, such as distraction, negotiation, or even socially inappropriate behaviors, to prevent being asked to do something.
• An intense need for control: Children with PDA may demonstrate domineering behavior, attempting to dictate the actions of others, including adults and peers.
• Sensitivity to ordinary demands: Even small requests may cause an extreme reaction, often due to a perception of threat to personal autonomy.

What Are the Symptoms of Pathological Demand Avoidance?

The symptoms of Pathological Demand Avoidance (PDA) can vary from child to child but typically include the following:

• Resisting everyday demands: This might include refusal to follow instructions or complete tasks at home or school. Children may react with extreme emotional outbursts or refuse altogether to engage in any requested activity.

• Use of strategies to avoid demands: These might include distracting, diverting attention, making excuses, or giving socially shocking responses or behaviors. Children with PDA may attempt to manipulate situations to avoid compliance, often using humor or charm to derail requests.

• Socially inappropriate behavior: This can manifest as overly controlling or dominating behavior in social interactions with peers and adults. They may act out in ways that seem to intentionally disrupt normal social dynamics.

• Extreme mood swings and emotional outbursts: Often triggered by demands or expectations, these outbursts can seem disproportionate to the situation. Responses can be dramatic and out of alignment with the nature of the request. Panic attacks and withdrawal are often exhibited. 

• High need for control: A child with PDA may have a strong desire to control their environment and the actions of others .This could result in a pattern of bossiness or constant negotiation.

What Causes Pathological Demand Avoidance? 

The etiology of Pathological Demand Avoidance is not fully understood, but it is suggested to be related to the broader autism spectrum and pervasive developmental disorders. However, controversy exists regarding its separate distinction within the pervasive developmental disorders. 

Research suggests PDA results from an atypical response to anxiety, having a strong neurobiological basis, where demands or expectations are perceived as overwhelming, causing the child to react defensively. It is also believed to be influenced by both environmental and genetic factors, however further research is needed to understand its full origin. It is suggested to be exacerbated by the child’s heightened anxiety, inflexibility and need for control. It is often seen in individuals with autism but it is not a subtype or separate diagnosis; The overwhelming resistance to demands is what differentiates PDA from typical autism. 

How Do You Treat Pathological Demand Avoidance?

Treating Pathological Demand Avoidance (PDA) requires an understanding of the child’s need for control and their sensitivity to demands. Therapies are often focused on reducing anxiety, promoting cooperation, and providing flexible, personalized support.

Available Therapies and Options:

• Psychological therapy: Cognitive-behavioral therapy (CBT) and other therapeutic interventions can help address anxiety and emotional regulation.
• Behavioral interventions: These approaches focus on rewarding cooperation and creating a positive association with completing tasks.
• Educational support: Tailored teaching strategies, like using humor, flexible approaches, and varied routines, can help engage the child in learning without overwhelming them.
• Speech and language therapy: These therapies can assist children in expressing their needs and managing social situations better.
• Mindfulness & Role Play: Encourage your child to be mindful of their emotions and utilize healthy coping skills to modulate them. Sensory tools may also be helpful if sensitivity to sensory stimuli is a contributing factor for the individual. Role-playing with your child is a healthy way to express their needs, deal with distress and help to promote healthier communication and increased distress tolerance skills. 
• Family therapy: Training and support for caregivers and family members can improve communication and reduce tension within the household.

How Can You Support A Child with Pathological Demand Avoidance?

There are a number of ways you can support your child with PDA within the context of home, school and overall social environments.

Home

• Be flexible: Adjust your expectations and routines. Instead of rigid demands, try to offer choices.
• Use humor, empathy and novelty: Engage in playful approaches to make tasks feel less like demands. Also, acknowledge and validate their experience, for instance, the difficulty they may be experiencing related to the presenting symptoms of this condition.
• Cultivate a calm environment: Keep stress and conflict to a minimum to prevent anxiety-triggered behaviors. Encourage your child to self-soothe, helping them discover helpful ways that work for them, including weighted blankets, stress balls or grounding exercises.  It is also important to ensure your child has sufficient nutrition, sleep and play time outside. All of these factors greatly contribute to overall health—body and mind. As a growing body of research indicates a connection between neuroinflammation, oxidative stress and gut imbalances in ASD, these foundational factors can be pivotal in modulating and supporting these processes. 
• Offer control: Allow the child to feel some control over their actions by offering them options.

School

• Work closely with educators: Ensure the school understands the child's needs and applies flexible strategies.
• Provide a safe space: A designated area for the child to retreat to if overwhelmed can help manage emotional overload.
• Adjust teaching styles: Use humor, interest-based tasks, and flexible deadlines to keep the child engaged without pressure.

Social Settings

• Prepare for social situations: Set expectations ahead of time, explaining any upcoming demands in a calm, non-threatening manner.
• Respect boundaries: Understand that social situations may be anxiety-inducing and allow time for adjustment.

When Should You Seek Help for a Child with Pathological Demand Avoidance?

If your child’s demand avoidance is severely impacting their life, it may be time to seek professional help. Signs that you should consult a professional include:

• Severe behavioral issues: Extreme resistance to demands that interfere with daily living.
• Social challenges: Difficulty maintaining friendships or participating in social situations due to controlling or disruptive behavior.
• Unmanageable anxiety: If the child’s anxiety is causing harm or significant distress.
• Difficulty in education: A child who struggles academically due to overwhelming resistance or emotional reactions to school demands.

Therapies and Professional Support to Consider:

• Psychologists: Specializing in autism spectrum disorders and behavior management.
• Occupational therapists: To help manage sensory sensitivities and promote emotional regulation.
• Speech-language therapists: To help with communication challenges.
• Behavioral therapists: For developing strategies that address problematic behaviors in a structured and thoughtful way. 

Next Steps

Supporting a child with Pathological Demand Avoidance involves a combination of understanding, flexibility, and patience. Building a routine that accommodates their need for control while still encouraging social engagement, learning, and self-regulation can be key to their development.

General Guidance for Supporting a Child with Pathological Demand Avoidance:

• Focus on creating an environment that minimizes anxiety and offers flexibility.
• Collaborate with healthcare providers, educators, and specialists to create a comprehensive support plan.
• Remember that managing PDA is an ongoing process—patience and consistent strategies are essential.

If you’re looking for more support for your child with Pathological Demand Avoidance, Handspring Health can help.

Schedule a free consultation with a licensed Handspring therapist to learn how we can support you in supporting your child with PDA.