Pathological Demand Avoidance

Pathological Demand Avoidance is widely understood as an autistic profile. It involves a persistent drive for autonomy that presents as avoidance of everyday demands and at times, the use of social strategies as part of this avoidance. Individuals with PDA have highly sensitive nervous systems, easily experiencing threat/danger response (PDA North America).

PDA traits overlap with other diagnostic criteria and can be incorrectly attributed to a variety of other conditions, which may make it difficult to ‘target’ exactly what is underlying the complex presentations. The most common conditions which may be confused with PDA are: Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), Reactive Attachment Disorder (RAD), Personality Disorders and Developmental Trauma.

It is important to keep in mind that PDA, like many other psychological conditions, is co-occurring. Meaning, there might be more than one thing going on; in fact, there almost always is.

Children with PDA may have various divergent/unique characteristics:

• Children may appear ‘actively passive’, not engaging with life, and/or may prefer to be an observer, including resisting/avoiding ordinary demands of life. For example, if you hand them something, they may let it drop from their hands with no concern.
• Children may come up with (ingenious) excuses to avoid demands, including using common social strategies as part of this avoidance.
• Children may seem sociable (at least on the outside); this may mask differences or difficulties in social interaction and communication.
• Because of high anxiety levels, children may be emotionally sensitive, quickly switching from passive to aggressive. Children with other types of ASD might have meltdowns; these aren’t as sudden and happen less often.
• Children may be imaginative, comfortable in role play, pretence, or fantasy. For example, they may role play by taking on the personality of their favourite cartoon character.
• A high need for control. Often driven by anxiety or an automatic ‘threat response’.
• Children may need unconventional teaching approaches. Conventional ways of parenting, teaching, or supporting are often ineffective with children with PDA

What is ODD Then?

ODD is described as ‘persistent negative, hostile and defiant behaviours’ towards authority. Superficially there may be some similarities with a PDA presentation, however ODD is not an autism spectrum profile. Points of difference include, the fact that the more ‘social’ avoidance approaches seen in PDA (e.g. distraction, making excuses or procrastination) are not usually seen with ODD; and positive parenting courses and reward-based approaches are beneficial for ODD, but ineffective for PDA.

Children with Pathological Demand Avoidance (PDA) experience heightened anxiety when faced with demands. Since demands persist and avoidance strategies are rarely completely effective, stress and anxiety often escalate. Given the central role of anxiety in PDA, some individuals refer to it as Pathological Demand Anxiety.

When the brain perceives a demand as a threat, cortisol levels increase, prompting the brain to employ various avoidance tactics. These may include lying, role-playing, ignoring, social manipulation, or other strategies to shield itself from the perceived threat. If these methods fail, the brain escalates its response, potentially leading to panic. In such a state, as illustrated in the hierarchy on the slide, individuals may exhibit behaviors like the silent treatment, tantrums, running away, aggression, or self-harm. This overwhelmed state is unfortunately common among those with PDA, especially if they have not been diagnosed or are misunderstood by those around them.

Demands Come in All Shapes and Forms

Some demands seen here don’t even seem like demands, such as: timetables, needs, and pecking order. But they are demands as well! Behind all demands there is some sort of expectation and behavioral implication.

Some common forms of demands with examples are:

• Direct demands/questions (e.g. Turn left here. Hand that to me.)
• Indirect demands/praise/expectations/time (e.g. the chicken will be cooked in 1 hr. You ‘re doing really great finishing your homework!)
• Demands within demands aka. Smaller implied demands (e.g. Going the post office requires getting dressed, getting in your car, driving, interacting with people, etc.)
• Daily life (e.g. taking a shower. Brushing your teeth.)
• Internal demands/thoughts/wishes (e.g. hunger, need for human interaction)
• Things we want to do (e.g. Go outside. Play our favorite instrument. Call your friend.)

What Parenting Approaches Can Help PDA?

The approaches that help PDA can seem a bit unconventional: a partnership based on trust, flexibility, collaboration, careful use of language and balancing of demands works best. To remember this try the acronym PANDA:

• Pick battles
• Anxiety management
• Negotiation and collaboration
• Disguise and manage demands
• Adaptation
• Strategies to Help Support those with PDA

Firstly, it is important to note that a good relationship goes a long way, therefore one should spend time getting to know the PDA individual better, whether you are their clinician or parent.  Secondly, as we have already touched on, everyone is unique! There is no, one size fits all approach, and therefore once a relationship is built, supporting individuals should exercise intuition.  Thirdly, one can never go wrong using calm and level emotions.

Now, as far as phrasing demands, one might use complex language to lead into a demand. It’s hard to refuse something when you don’t know what you are really being asked. Novelty and variety can also work well used alongside flexibility and adaptability. Disguising demands has been particularly useful through the use of role playing specifically.

Lastly, potentially less helpful (but good when used in tandem with the previous approaches just mentioned) visual structures can be really helpful, such as including ground rules which are displayed on the wall so that you can refer to them.

Useful Ways of Concealing Demands

• Would you do…
• Could you…
• If you’re happy to…
• When you have finished with…could you…
• Do you mind going/doing…
• Is it ok with you…
• How do you feel about…
• I wish I knew someone who could help with…
• Look at that, now it’s time to…
• You choose, what job shall we do next…
• I bet you can’t do…in five minutes

Reducing anxiety

The main issue in young people with PDA is anxiety and if you are able to reduce this, maladaptive behaviours may reduce in severity. Various anxiety reduction techniques can be used when PDA individuals become overwhelmed:

• Stress reduction breathing
• Meditation
• Removal from the situation
• Progressive Muscle Relaxation (PMR)

Other approaches which may be useful are speaking in the third person, requesting rather than demanding and offering a choice of two. Finally, depersonalizing a demand may help, such as ‘the whole family are going to’.