What is Pathological Demand Avoidance (PDA)

September 21, 2020 The Ed Psych Practice 1 Comment Referrals ADHD, Anxiety, Autism Profile, Avoidance Tactics, Indirect Demands, Mental Health, Occupational Therapists, PDA, Persuasive Development Disorder, Speech and Language Therapists

Takeaway: Pathological Demand Avoidance (PDA) is a subtype of Autism Spectrum Disorder (ASD), where children compulsively try to avoid any demands and requests from other people. These are stressful, so avoiding them feels good. But only for a bit. Then the anxiety comes back even stronger and slowly takes over their lives. Thankfully PDA can be managed if diagnosed early enough. So, it’s worth consulting a specialist for an assessment and a custom care plan.

Autism is part of a spectrum of related developmental differences. And that’s why it’s called Autism Spectrum Disorder (ASD)

It refers to a range of conditions that result from a child’s brain developing differently. These developmental differences change the way autistic children engage with the world, and gives them a unique set of strengths and weaknesses. So, your child might be able to hyperfocus on topics or subjects that interest her — dinosaurs, for example. But she might struggle to read people’s body language and facial expressions, which makes it harder to communicate. Each child experiences autism differently, though, which is why we think of the autism spectrum as having many subtypes. (Learn more about autism spectrum disorder [ASD].)

Pathological demand avoidance (PDA) is a subtype (or ‘profile’) of the autism spectrum.

The term was coined by British psychologist Elizabeth Newson when she noticed how some autistic children would shirk demands as a way of feeling in control of a situation. The key here is that your child has high anxiety levels and feels extreme pressure when anyone makes a demand or expects her to do something. So, she starts to avoid these demands as a way of calming herself.

All of us avoid anxiety-provoking things from time to time, but PDA is a little more extreme.

The avoidance happens almost compulsively, everywhere. And heart-breakingly, your child perceives even her own expectations as demands that need to be avoided. It’s like she’s in an ever-tightening web! The underlying logic (which she probably isn’t aware of) is, “If someone expects something from me, then I lose control of the situation, and that’s horrible. But if I refuse the demand, then I’m back in control, and safe.”

PDA is quite controversial, though, and hard to diagnose. In fact, it’s not in any of the diagnostic manuals that healthcare professionals use.

The PDA profile is quite young — some of the studies about it were done as recently as 2016. So, many professionals still question how valid this autism subtype is. And to complicate things, many PDA characteristics overlap with those of other conditions like Attention-Deficit/Hyperactivity Disorder (ADHD). This is why it’s not yet in the DSM-V (the Diagnostic and Statistical Manual of Mental Disorders, Edition 5), which is the gold standard for most professional diagnoses. Still, PDA perfectly describes a certain type of autism and makes it easier to create customised care plans for the children.

You’ll notice that PDA has two essential components: (1) A demand, and (2) The avoidance of that demand.

Here are some of the more common demands your child might react to:

A direct demand. For example, ‘Sit down and finish your homework’ or ‘Are you hungry? Here, eat this. It’s tasty!’
An indirect demand.g., When you say, ‘You ran that race really well!’, your child might be hearing ‘…So now you need to run all races well.’
A batch of related demands. For example, asking your child to go on a school trip might seem like a single request. But there’s more to it than that. She’ll need to travel on a bus, go to new places, eat food she doesn’t really like, and talk to people she’s not totally comfortable with.
Her own expectations. She might have a personal to-do list, like bathing, studying, and playing with her friends.

To avoid a demand, your child might try one of these tactics.

She’ll likely work through a range of techniques — mild ones initially and more extreme ones later. Here are some examples:

Distraction. If you ask her to do her homework, she might counter by asking for help finding a book she’s lost.
Starting a different conversation. If you ask her to have a bath, she might tell you an interesting story about something that happened to her at school.
Giving excuses. If you ask her to get off the computer, she might say she’s watching a really important video.
Creating a problem. If you ask her to get ready for school, she might say she’s not feeling well and is too tired to move.
Withdrawing into fantasy. If you ask her to get into bed, she might say, ‘I’m a bird, and birds don’t sleep in beds.’
Getting aggressive. If these subtler tactics don’t work, she might get more anxious and start shouting or breaking things.
Having a meltdown. When all else fails, she’ll likely have a meltdown (think of it as being the same as a panic attack). Meltdowns can be traumatic for her and we want to prevent things from escalating this far.

PDA is a part of autism spectrum disorder (ASD) but it has some unique characteristics.

Here’s why many specialists think of PDA as a distinct subtype of ASD.

Being ‘actively passive.’ Children with PDA don’t engage with life much and prefer to just watch it pass by. For example, if you hand them something, they might let it drop from their hands with no concern. In contrast, most autistic children aren’t passive. Rather, their challenge is being sociable.
Coming up with excuses. Children with PDA tend to actively avoid demands and often come up with ingenious excuses. Other autistic children often just ignore these demands or react to them more directly.
Appearing sociable. Children with PDA may seem quite socially able (at least on the outside), whereas other autistic children don’t.
Emotionally fragile. Because of their high anxiety levels, children with PDA might quickly switch from passive to aggressive. Children with other types of ASD might have meltdowns, but these aren’t as sudden and happen less often.
Very imaginative. Children with PDA might, for example, play by taking on the personality of their favourite cartoon character. This level of fantasy-play isn’t common with other types of ASD.
Social obsessiveness. Children with ASD tend to obsess about routines and their physical environment. In contrast, children with the PDA subtype usually have social obsessions — i.e., they focus on the demands people place on them.

So, how can you help your child if she has PDA? Here are 2 things you can do.

1. Take her to a professional who can officially diagnose her.

Although we don’t want to label or limit your child, an official diagnosis is useful. It helps us decide how best we can help her. The diagnosis usually involves two sets of assessments — the Autism Diagnostic Observation Schedule (ADOS) and theAutism Diagnostic Interview-Revised (ADI-R).

2. Learn healthy ways of encouraging and supporting her

Here are some simple steps you can take.

Figure out what to be firm about and what to let go. You’ll want to help her face some of her fears, but you’ll also need to realise that she has her limits. So, be patient, gentle, accommodating, and always have a plan B.
Help her understand what’s going on. Try to explain why you’re asking her to do things that make her anxious. And get her involved in planning approaches to different challenges.
Plan ahead to manage anxiety. Recognise the situations and demands that will tax her the most, and plan for them. Try to reduce uncertainty where possible, and if she has a meltdown, try to support her and move past it. It’ll help her to learn that being anxious is okay and can be managed.
Keep things fun. Doing hard things doesn’t have to make her miserable. Try and keep the atmosphere light, help her to see the funny side of things, and harness her imagination through role-play.
Learn to disguise demands. Try to make requests instead of demands, and keep them as indirect as possible. For example, ‘Let’s go for a movie’ is worse than ‘Do you want to go for a movie?’ Even better would be to phrase it as ‘The whole family is going for a movie. Why don’t you join us?’ You could even throw in a choice, to take the pressure off further — ‘Do you want to go for a movie or play in the park?’

Learning to support your child can be tough but rewarding.

Children don’t outgrow PDA, but they can learn to manage it. Do remember that what works for someone else may not work for your child. For example, many children with ASD might respond well to ‘reward charts’ and well-planned routines. But these are rarely useful for children with PDA. So, with the help of a specialist, you’ll need to develop a flexible plan tailormade for your child. It’s slow work, but every small victory will make her a little less anxious. And that’s such a worthwhile goal.

Do you think your child might have ‘demand avoidance’ issues? Consider consulting a specialist.

The Ed Psych Practice offers consultation, advice, and problem solving for parents, nurseries, schools, and colleges, in London. We havepaediatricians, psychologists and therapists who can help assess your child and offer guidance and support.

Phone: +44 (0) 78 3344 7356
E-mail: Office@TheEdPsych.com