Pathological demand avoidance

Pathological demand avoidance (PDA), also known as "persistent drive for autonomy,"Neff, Megan. Autism PDA Explained: The Core Characteristics of Pathological Demand Avoidance, Neurodivergent InsightsService, Anson. Pathological Demand Avoidance (PDA) Reframed, Spectrum Life Magazine is a proposed autism subtype involving severe anxiety when faced with demands. People with PDA tend to feel threatened by demands and may go to extreme lengths to avoid doing things that cause them anxiety.
Anxiety can be triggered by routine activities (e.g. tooth-brushing), preferred activities (e.g. getting ready to leave the house to go somewhere fun), or even biological needs (e.g. the need to drink when thirsty).Types of avoidant behavior
While signs of PDA first show up in childhood, it has been observed continuing into adulthood.Chambers, Kyra. For the Love of Roleplay, Vocal Media While there is no known cure for PDA, the right support may be able to improve quality of life.
Professor Elizabeth Newson first coined the term in the 1980s.Gillette, Hope. Pathological Demand Avoidance (PDA) in Autism, Psych Central
Currently, researchers do not believe there is enough evidence to consider it a separate syndrome.Green, Jonathan et al. Pathological Demand Avoidance: symptoms but not a syndrome, The Lancet. More research is needed.Kildahl, A. N., Helverschou, S. B., Rysstad, A. L., Wigaard, E., Hellerud, J. M., Ludvigsen, L. B., & Howlin, P. (2021). Pathological demand avoidance in children and adolescents: A systematic review. Autism, 25(8), 2162-2176. https://doi.org/10.1177/13623613211034382 Some label it as a behavioral profile of autism.
==Signs==
===Demand avoidance===
"Demands, particularly external ones, cause me great distress, even if I want to participate or do the action, every suggestion always has a knee-jerk ‘NO!’ response." Kyra Chambers, adult with PDADemand avoidance is the most prominent trait of PDA. While typical children can be uncooperative and go through phases (e.g. the "terrible twos"), this resistance is extreme and interferes with everyday life. It is not intentional and is highly stressful for the person with PDA.Demand avoidance, National Autistic Society
There are 3 types of demands:
#Direct demands (instructions given by others)
#Internal demands (e.g. wanting to complete a task needing water when thirsty)
#Implied demands (e.g. someone expecting an answer to their question or a bill that needs paying)
All of these demand types can trigger anxiety and provoke resistance.
People with PDA can use diverse and creative ways to resist stressful demands. This may appear manipulative to onlookers.O'Nions E, Gould J, Christie P, Gillberg C, Viding E, Happé F. Identifying features of 'pathological demand avoidance' using the Diagnostic Interview for Social and Communication Disorders (DISCO). Eur Child Adolesc Psychiatry. 2016 Apr;25(4):407-19. doi: 10.1007/s00787-015-0740-2. Epub 2015 Jul 30. PMID: 26224583; PMCID: PMC4820467. Demand avoidance methods can include:
*Excuses, including role-playing (e.g. "I can't brush my teeth because I'm a cat and cats don't have hands")
*Negotiations
*Distractions, including socially shocking behavior
*Refusal
*Passivity/withdrawal
*Outbursts, including aggression (which is typically a last resort)
When a person cannot avoid a demand that they are afraid of doing, they may experience a meltdown, panic attack, or aggressive outburst. This is driven by anxiety and is different from willful misbehavior.
===Other traits===
Other traits include:Identifying & Assessing PDA, PDA Society
*Need for control
*Enjoyment of role-playing
*Obsessive behavior, possibly including obsessions with other people
*Impulsivity
*Ambivalence about success (including destroying their own work after someone praises it)
*Rapid mood swings
*Above-average concrete language skills and vocabulary
*Interpersonal difficulties
*Superficial social skills while struggling to understand situations
*Difficulty understanding boundaries, sometimes including harassment of others
*Atypical social understanding (e.g. believing that rules only apply to other people or that they have the same authority as an authority figure)
Children with PDA may be misinterpreted as "naughty" when they are struggling. They may end up internalizing this negative image, resulting in poor self-esteem.Marschall, Amy. Pathological Demand Avoidance in Autism and Beyond, VeryWell Mind
Common strengths of people with PDA include independence, strong sense of justice, charisma, creativity, imagination, humor, and tenaciousness.
===Comparison to typical autism===
People with PDA tend to be more socially advanced and socially oriented than typical autistic people, with more instances of extreme behavior. They also are extremely imaginative and comfortable with pretend play. While autistic people tend to pay little attention to social hierarchy, people with PDA desire to be equal or superior to others.Information for education professionals, PDA Society
Relative to typical autistic people, they may make more frequent eye contact. Their repetitive behaviors (e.g. stimming) and routines may be less obvious.
===Masking===
Neurodivergent masking is common among people with PDA. Children with PDA may internalize more at school and externalize more when safe at home. Thus, other people may hesitate to believe parents when they express concerns about their child.
==Evaluation==
PDA is not medically recognized and thus can't be officially diagnosed.
The Extreme Demand Avoidance Questionnaire (EDA-Q) was developed for research purposes. It is not an official diagnostic measure.The Extreme Demand Avoidance Questionnaire (EDAq), PDA Society A shortened 8-question version is available online.Extreme Demand Avoidance 8-item measure (EDA-8) (PDF). PDA Society
==Treatment==
There is little information about treating PDA. More research is needed.
===Medical and therapeutic===
Since PDA involves anxiety, treatment for anxiety is a possible approach. Conventional anxiety treatments include medication and counseling such as cognitive behavior therapy and dialectical behavior therapy. However, the efficacy of these methods for PDA needs further study.
Like typical autistic people, people with PDA often struggle with sensory processing difficulties. Treating this problem may help reduce the impact of sensory stressors.
===Caregiving approaches===
“The classic relationship of authority versus submissive, it just doesn’t work. You always have to take a step back and not think like that anymore." ParentSyson, Zoe and Langton, Emma. Simple strategies for supporting children with Pathological Demand Avoidance at school (PDF). PDA SocietyConventional caregiving advice, such as using positive reinforcement, does not help when caregiving for people with PDA.
Experts recommend the following:Fidler, Ruth. Meeting the educational needs of pupils with a PDA profile, National Autistic SocietyNeff, Megan. Low-Demand Parenting and Why It's Important, Neurodivergent InsightsHelpful approaches with PDA – children, PDA Society
*Reducing anxiety and promoting wellbeing
*Paying attention to the person's stress levels to avoid giving them more tasks than they can handle
*Allowing extra processing time
*A low arousal approach
*Offering more choice and control
*Integrating the person's interests
*Avoiding "no-win" situations
*Collaborating with the person to make tasks easier
*Reducing and prioritizing demands
*Recognizing that some days will be harder for the person than others
*Staying calm
Indirect demands may be easier for people with PDA. Indirect language (e.g. "I wonder if we could" versus "you must") can feel less threatening. Creative solutions, like having the child control a puppet that does the task, may also help.
Social stories may help children with PDA learn how to handle social situations.
The PDA Society recommends 5 "golden rules:" thinking ahead, giving the person advance notice, reducing demands when the person is stressed, creating a calm space to retreat to, and keeping calm in the face of the person's distress.
===Self-help===
Adults with PDA report making lifestyle adaptations to handle their reflexive desire to avoid things. These include roleplay, reverse psychology, telling themselves they do not have to do something, distraction, automating tasks, completing other tasks while avoiding a different one, networking with other PDA adults, and avoiding overtaxing themselves.Ryuki, Riko. Adult coping strategies, Riko's blog: PDA and more.15 Life Hacks for PDA (Pathological Demand Avoidance), NeuroClasticSelf-help, coping strategies and therapies for adult PDAers, PDA Society
==Controversies==
PDA is not currently medically recognized and whether it should be is a subject of debate. Two common questions arise: is the evidence base sufficient, and is PDA a real condition or just an unfair way to pathologize autistic people's behavior?
Some critics argue that the PDA label blames the individual while ignoring their unmet needs, suggesting that PDA traits would go away if the person had adequate support. They believe the PDA label pathologizes autistic people for behaving in ways outside social norms, resisting being placed in distressing situations, and asserting their agency.Moore, A. (2020). Pathological demand avoidance: What and who are being pathologised and in whose interests? Global Studies of Childhood, 10(1), 39-52. https://doi.org/10.1177/2043610619890070Pathological demand avoidance, autism, & ADHD, Embrace Autism
People who identify with PDA contend that the critics do not understand their experiences.
==See also==
*Anxiety disorders
*Autism
*Neurodivergent masking
==External links==
*PDA Society
*PDA North America
==References==
Category:Autism
Category:1980s