Pathological Demand Avoidance Syndrome (PDA)

In recent years, Pathological Demand Avoidance (PDA) has been more widely recognised as a profile most commonly seen in individuals on the Autism Spectrum. This avoidance has been described as ‘pathological’ because it is driven by the individual’s innate desire to minimise anxiety or reduce fear that is associated with anticipated or unanticipated demands. ‘Pervasive’ or ‘extreme’ are alternate terms, as is ‘demand avoidant profile.’ Some individuals prefer to refer to PDA as a ‘Pervasive Drive for Autonomy.’

Individuals with PDA can present with significant resistance and avoidance towards a range of demands and expectations, including those interpreted to be innocuous or mundane, such as daily routines or social interactions. This level of avoidance can lead to considerable disruption to a young person’s everyday functioning and participation in daily occupations. 

There are numerous developmental or behavioural profiles that often resemble PDA, and this presentation can commonly be mistaken for other conditions, such as Oppositional Defiant Disorder (ODD) or other anxiety-related disorders. Given this, it is important to seek a professional evaluation if it is suspected that your young person may be presenting with indicators or signs of PDA. With the assistance of early intervention, support and understanding, many individuals with PDA experience success and happiness in daily life. 

Ultimately, the direct cause for PDA remains unknown and there is much to be learnt about PDA symptomology and diagnosis. Numerous factors may underpin the anxiety or distress triggered by demands and expectations in individuals with a PDA profile. Research suggests that PDA may be caused by a disruption in typical development of body’s sympathetic nervous system, which directly impacts on how the brain processes and responds to stress or anxiety. Individuals with PDA can have a very narrow window of tolerance and thus their stress response is easily activated, in which the body enters fight-or-flight in response to a demand. Many young people with a PDA profile can concurrently experience significant sensory processing difficulties, which directly impacts upon their ability to appropriately self-regulate and manage unexpected situations. 

It is commonly seen that young people with PDA can employ a range of strategies and tactics to try and avoid demands. Some tactics employed can be quite discrete, such as distraction, increased dialogue to leave no space for further questioning, asking questions, and formulating excuses as to why they are unable to engage. Other avoidance strategies can be more overt, such as sabotaging, refusing, agitation, heightened verbal responses, behavioural escalations, freezing or shut down, absconding, physical responses towards environment or others, and self-harming. Individuals with PDA commonly demonstrate a degree of ‘surface sociability’, in which they appear socially motivated, but harbour underlying difficulties in their social reciprocity, maintenance of social relationships and appropriateness of social conduct. It is important to note that individuals with a PDA profile, including children and young people, are often quite skilled in masking or concealing their social difficulties and therefore the true nature of their avoidance is not always outwardly obvious to others. The key distinctive features of a demand-avoidant profile include: 

• Significant and persisting anxiety 
• Perceived loss of autonomy which activates a threat response 
• Significant resistance to everyday demands and ordinary requests 
• Sudden changes in mood 
• Impulsivity 
• Strong need to obtain or maintain control 
• Rigid and inflexible thinking 
• Demonstrating socially calculating or overt behaviour to avoid demands 
• Feeling most comfortable in role play and pretend contexts 
• Processing challenges and language delays 
• Avoiding demands to an extreme extent and to their own detriment, including things they enjoy 
• Tendency not to respond to ‘conventional’ parenting or support strategies 

It is important to note that marked demand avoidance may have multiple underlying causes and by no means do all individuals displaying these behaviours have a PDA profile. In fact, a true underlying PDA profile is uncommon, although there is increasing awareness and understanding around this. For those with a PDA profile, avoidance of demands can be all encompassing, and is not a choice. 

There is no one approach to supporting a young person with PDA and, importantly, supportive strategies that work on one day might not work the next. It is essential that all those supporting in a young person with PDA’s care are adaptive and flexible in their approach. 

Creating a low demand environment can be incredibly supportive for many young people with PDA. This involves reducing expectations within plans and tasks, and providing an increased sense of autonomy. Allowing choice where possible is imperative, with decisions made collaboratively and with negotiation. Low demand does not mean ‘no rules’, and safety boundaries need to be enforced as required. However, leaning into a low demand environment can help individuals with PDA to make the choice to engage in tasks and expectations. Reducing demands does not mean ‘failure’; it means validation and respecting a person’s capacity.  

Language is a key part of this – using indirect language rather than direct requests or commands (‘I wonder if we can…’ rather than ‘You have to do…’), employing ‘intentional nonchalance’, and avoiding trigger words (no, can’t, stop don’t etc).