07 Jun What is pathological demand avoidance — or PDA?
By Emma Timmins, Clinical Psychology Registrar
Pathological demand avoidance or PDA is a profile of autism that involves extreme avoidance to the normal ‘demands’ of life.
Everyone has some level of demand avoidance – think of the time you got home from a nice dinner and you couldn’t be bothered to take your makeup off or brush your teeth. But, for someone with PDA, many ordinary demands of life trigger an automatic anxiety response
What are the signs of PDA?
PDA involves the avoidance of everyday demands, such as getting out of bed for school. and the use of social strategies as a component of the avoidance.
Here are some of the signs of PDA:
- Resisting and avoiding demands that occur in everyday life
- Mimics socially acceptable behaviours that may mask underlying difficulties with social skills and interaction
- Experiences intense emotions and mood swings
- Finds role play or fantasy easy
- Has intense focus, typically on others
- Has a need for control, typically driven by anxiety that feels automatic
The link between PDA and autism
PDA is commonly recognised as a profile of autism. However, there is no universal agreement on how PDA fits with autism. Autistic kids who fit the PDA profile have an extreme avoidance to life’s daily demands. This is not the case for every person with autism, so not every autistic person has PDA. Kids with PDA can also be obsessive, and sometimes they are misdiagnosed with obsessive-compulsive disorder.
This video provides some insights into what it’s like being autistic and having PDA, created by an artist with lived experience.
What triggers pathological demand avoidance?
There are many demands on us throughout the day, such as choosing which socks to wear and following the rules at work or school. A neurotypical person may not consider many activities as demanding, but a child with PDA may respond to the same demand with a feeling of anxiety or panic.
Some of the demands that may trigger PDA include:
- Direct demands
- Implied demands
- Visual instructions
What does PDA look like at school?
PDA can appear different in the home versus the school setting. Here are some of the behaviours and emotions a child may experience at school:
- Has difficulty attending school. (This should not be seen as truancy.)
- Struggles with emotion regulation
- Finds it hard to receive praise.
- Uses charm, imagination or shock tactics as a component of avoidance.
- Appears to manage social interactions.
- Perceive themselves as equal to adults or possibly reserve roles with you
- Appears resilient, but may mask poor self-esteem.
- Desires friendships, but these can be sabotaged by a need for control.
How is pathological demand avoidance diagnosed?
PDA is a fairly new concept. According to the National Autistic Society in the UK, the term ‘pathological demand avoidance’ first appeared in a journal article in 2003. It hasn’t made it into the DSM yet, which is the manual used by psychologists and psychiatrists to make a diagnosis. That means there is no formal diagnosis for PDA. However, it’s worth talking to a psychologist about PDA if you think your child fits the criteria.
A psychologist or other paediatrician may assess your child for other developmental or psychological issues, especially if your child does not have a current diagnosis. This might include an autism assessment. A psychologist can also discuss PDA with you and whether your child fits the profile. We have several psychologists at Spencer Health who specialise in autism and PDA in children.
How is PDA treated?
There is no “treatment” or “cure” for PDA. People with autism and PDA are born with neurological differences, just as anyone is born with other kinds of differences.
PDA can make it challenging for individuals to manage day-to-day life. There are different skills a person with PDA may wish to learn in order to help them manage demands, anxiety, and social interactions.
Intervention can help a child with PDA develop skills and strategies to navigate and manage life’s demands. These goals for therapy should be established with the individual, and aligned to their goals. The individual may be supported in these goals by a range of professionals including psychologists, occupational therapists, psychiatrists or paediatricians.
PDA may also cause other mental health challenges such as anxiety or depression. These issues should be addressed through any intervention plan.
How can I support a child with PDA?
The Pathological Demand Avoidance Society, UK (2022) recommends an approach that is flexible, based on trust, and collaborative. Use language carefully and balance demands. This is called the PANDA approach, as outlined below.
1. Pick battles
Minimise rules, and let the child have some choice and control. Explain the reasons certain tasks are important, and accept that some tasks may not be completed.
2. Anxiety management
Try to reduce uncertainty, including having a routine. Recognise underlying anxiety and any social and/or sensory challenges. Plan ahead as much as possible. Respond to signs of distress to help calm the child.
3. Negotiation and collaboration
Keep calm and proactively collaborate and negotiate to solve challenges. At times, it will be beneficial for the child to take the lead.
4. Disguise and manage demands
Phrase any requests indirectly. It is important to monitor tolerance for demands and match demands accordingly. It will be beneficial to complete demands together.
Try humour, distraction, novelty and role play. Try to have a Plan B and allow plenty of time for activities to be completed. Try to balance the amount of ‘give and take.’
Where can I get help?
Contact Spencer Health for a consultation for you and your child. A psychologist can provide advice on next steps, including whether your child would benefit from a formal assessment for autism, or other developmental or mental health issues.
Your child may be able to better manage their daily life with early intervention, such as ongoing social skills therapy or counselling.
Information has been adapted from the Pathological Demand Avoidance Society, United Kingdom (2022).