Pathological demand avoidance

The primary sign is an atypical resistance to normal, everyday social demands. For the purposes of PDA, a demand may be presented within a social interaction, or it may involve another direct or implied expectation to cooperate.{{Cite book |last=Truman |first=Clare |url=https://books.google.com/books?id=NTQlEAAAQBAJ&q=%22Pathological+demand+avoidance%22 |title=The Teacher's Introduction to Pathological Demand Avoidance: Essential Strategies for the Classroom |date=2021-07-21 |publisher=Jessica Kingsley Publishers |isbn=978-1-78775-488-1 |pages=15–22 |language=en |chapter=PDA – What do we know so far?}} It encompasses things that are interpreted as demands, such as being told to do homework, as well as societal expectations or requests (e.g., someone silently offering to shake hands). Individuals with PDA display a resistance to everyday demands in a manner that is obsessive and dramatically beyond typical behavior.{{cite journal |vauthors=O'Nions E, Gould J, Christie P, Gillberg C, Viding E, Happé F |date=April 2016 |title=Identifying features of 'pathological demand avoidance' using the Diagnostic Interview for Social and Communication Disorders (DISCO) |journal=European Child & Adolescent Psychiatry |volume=25 |issue=4 |pages=407–419 |doi=10.1007/s00787-015-0740-2 |pmc=4820467 |pmid=26224583}} The resistance to demands may also apply to demands that they make on themselves, such as preparing for a self-chosen favorite activity, and even to internal demands such as hunger or the need to use the restroom.{{Cite book |last1=Fidler |first1=Ruth |title=Navigating PDA in America: A Framework to Support Anxious, Demand-Avoidant Autistic Children, Teens and Young Adults |last2=Gould |first2=Diane |publisher=Jessica Kingsley Publishers |year=2024 |isbn=9781839972744 |location=London}}

When people with PDA perceive a demand, they often use socially strategic tactics to avoid it. For example, they may try to ignore the demand or distract the person issuing the demand by changing the subject, offering imaginative excuses, or renegotiating agreements on when the demand will be fulfilled.{{cite journal |vauthors=O'Nions E, Gould J, Christie P, Gillberg C, Viding E, Happé F |date=April 2016 |title=Identifying features of 'pathological demand avoidance' using the Diagnostic Interview for Social and Communication Disorders (DISCO) |journal=European Child & Adolescent Psychiatry |volume=25 |issue=4 |pages=407–419 |doi=10.1007/s00787-015-0740-2 |pmc=4820467 |pmid=26224583}} If the demand persists, a PDAer may escalate to intentionally shocking behavior, such as (in children) deliberately kicking someone to get out of doing something; shame or remorse for such inappropriate or infantile behavior is often not communicated.{{Cite book |last=Truman |first=Clare |url=https://books.google.com/books?id=NTQlEAAAQBAJ&q=%22Pathological+demand+avoidance%22 |title=The Teacher's Introduction to Pathological Demand Avoidance: Essential Strategies for the Classroom |date=2021-07-21 |publisher=Jessica Kingsley Publishers |isbn=978-1-78775-488-1 |pages=15–22 |language=en |chapter=PDA – What do we know so far?}}{{Cite journal |last1=Egan |first1=Vincent |last2=Linenberg |first2=Omer |last3=O’Nions |first3=Elizabeth |date=February 2019 |title=The Measurement of Adult Pathological Demand Avoidance Traits |journal=Journal of Autism and Developmental Disorders |language=en |volume=49 |issue=2 |pages=481–494 |doi=10.1007/s10803-018-3722-7 |issn=0162-3257 |pmc=6373319 |pmid=30140985}}

PDA is a spectrum, meaning its symptoms present differently depending on the individual. For example, PDA can be identified as internalized or externalized. Someone with internalized PDA may become withdrawn when they are triggered, rely on less obvious social strategies to avoid demands, and even comply in a perfectionistic manner in an attempt to neutralize the threat of the demand.{{Cite web |last=appointments@sunfieldcenter.com |date=2023-05-27 |title=Identifying and Navigating PDA |url=https://sunfieldcenter.com/identifying-and-navigating-pda/ |access-date=2024-02-01 |website=Sunfield Center |language=en-US}} Internalized PDA reactions are no less intense than externalized reactions; they are simply more hidden from public view. Furthermore, those with internalized PDA are more likely to experience avoidance behaviors when their trigger came from an internal decision.{{Cite web |date=2022-12-09 |title=Pathological Demand Avoidance and ADHD |url=https://psychcentral.com/adhd/pathological-demand-avoidance-adhd |access-date=2024-02-01 |website=Psych Central |language=en}} Externalized PDA includes an individual being expressive with their reactions when they have been exposed to a trigger, possibly resulting in meltdowns, panic attacks, controlling behavior, aggression, and anxiety.{{Cite web |last=PDAadmin |title=What is demand avoidance? |url=https://www.pdasociety.org.uk/what-is-pda-menu/what-is-demand-avoidance/ |access-date=2024-02-01 |website=PDA Society |language=en-GB}}{{Cite web |title=Pathological Demand Avoidance in Kids |url=https://childmind.org/article/pathological-demand-avoidance-in-kids/ |access-date=2024-02-01 |website=Child Mind Institute |language=en-us}}

The term was proposed in 1980 by British child psychologist Elizabeth Newson.{{cite journal |vauthors=Newson E, Le Maréchal K, David C |date=July 2003 |title=Pathological demand avoidance syndrome: a necessary distinction within the pervasive developmental disorders |journal=Archives of Disease in Childhood |publisher=Royal College of Paediatrics and Child Health |volume=88 |issue=7 |pages=595–600 |doi=10.1136/adc.88.7.595 |pmc=1763174 |pmid=12818906}}{{cite book |url=https://books.google.com/books?id=1-UztWdBkPkC&pg=PA181 |title=A History of Autism: Conversations with the Pioneers |vauthors=Feinstein A |publisher=Wiley-Blackwell |year=2010 |isbn=978-1-4051-8654-4 |page=181}} PDA is observed in adults as well.{{cite web |title=Pathological Demand Avoidance: an adults perspective |url=https://www.autism.org.uk/advice-and-guidance/professional-practice/pda-adults|archive-url=https://web.archive.org/web/20210119002635/https://www.autism.org.uk/advice-and-guidance/professional-practice/pda-adults|url-status=dead|archive-date=19 January 2021}}

The limited representation of adults in the literature makes it difficult to determine how demand avoidance behaviors present in adulthood.{{cite journal | last1=Johnson | first1=Matt | last2=Saunderson | first2=Helen | title=Examining the relationship between anxiety and pathological demand avoidance in adults: a mixed methods approach | journal=Frontiers in Education | publisher=Frontiers Media SA | volume=8 | date=2023-07-11 | issn=2504-284X | doi=10.3389/feduc.2023.1179015 | doi-access=free }}{{Cite news|url=https://www.psychologytoday.com/nz/blog/beyond-mental-health/202408/what-does-pathological-demand-avoidance-look-like-in-adults|title=What Does Pathological Demand Avoidance Look Like in Adults?|last=Gerlach|first=Jennifer|date=13 Aug 2024|publisher=Psychology Today|access-date=28 Mar 2024}} One of the reasons for this is the absence of a reliable tool for systematically studying these traits in adults.{{cite journal | last1=Egan | first1=Vincent | last2=Linenberg | first2=Omer | last3=O’Nions | first3=Elizabeth | title=The Measurement of Adult Pathological Demand Avoidance Traits | journal=Journal of Autism and Developmental Disorders | volume=49 | issue=2 | date=2019 | issn=0162-3257 | pmid=30140985 | pmc=6373319 | doi=10.1007/s10803-018-3722-7 | doi-access=free | pages=481–494 | url=https://link.springer.com/content/pdf/10.1007/s10803-018-3722-7.pdf | access-date=2025-03-05}}

Lacking a solid scientific foundation, professionals, lay people and adults with PDA have created support websites.{{cite web | title=Life with PDA | website=PDA Society | date=2024-09-23 | url=https://www.pdasociety.org.uk/community/life-with-pda/ | access-date=2025-03-06}}{{cite web | title=living with pathological demand avoidance: strategies for dealing with PDA | website=Rachelle Bloksberg | date=2024-07-19 | url=https://rachellebloksberg.com/living-with-pathological-demand-avoidance-strategies-for-dealing-with-pda-in-adults-for-autism-and-adhd/ | access-date=2025-03-06}}{{cite web | title=Understanding Pathological Demand Avoidance in Adults | website=NeuroSpark Health | url=https://www.neurosparkhealth.com/blog/understanding-pda-in-adults | access-date=2025-03-06}} An exploration of how adults with PDA experience daily life has been performed.{{cite journal | last1=Kenny | first1=Neil | last2=Doyle | first2=Alison | title=A phenomenological exploration of the lived experience of adults experiencing pathological demand avoidance | journal=Neurodiversity | publisher=SAGE Publications | volume=2 | year=2024 | issn=2754-6330 | doi=10.1177/27546330241277075 | page=| doi-access=free }}

PDA has never been included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD), and therefore has no diagnostic criteria. To be recognized, a sufficient amount of consensus and clinical history needs to be present, and as a newly proposed condition, PDA had not met the standard of evidence required at the time of recent revisions, however, patients that exhibited PDA behaviors were later diagnosed with autism using the DSM.{{Citation |last=Woods |first=Richard |title=Pathological Demand Avoidance (PDA) |date=2020 |encyclopedia=Encyclopedia of Autism Spectrum Disorders |pages=1–3 |url=http://dx.doi.org/10.1007/978-1-4614-6435-8_102293-2 |access-date=2024-02-23 |place=New York, NY |publisher=Springer New York |doi=10.1007/978-1-4614-6435-8_102293-2 |isbn=978-1-4614-6435-8|url-access=subscription }}

The 26-item Extreme Demand Avoidance Questionnaire (EDA-Q) was designed for research, but has been used as an aid to identification in children. {{cite web|title= A Parent's Guide to Understanding Pathological Demand Avoidance (PDA) - Part of the Autism Spectrum|url= https://www.molis.dk/gfx/pdf/For%C3%A6ldreGuide%20pa%CC%8A%20engelsk%20flyer.pdf|website=Molis |location= Denmark|access-date=27 February 2025}} In 2021, this was reduced to an 8-item questionnaire (EDA-8).{{Cite journal |last1=O’Nions |first1=Elizabeth |last2=Happé |first2=Francesca |last3=Viding |first3=Essi |last4=Noens |first4=Ilse |date=September 2021 |title=Extreme Demand Avoidance in Children with Autism Spectrum Disorder: Refinement of a Caregiver-Report Measure |journal=Advances in Neurodevelopmental Disorders |language=en |volume=5 |issue=3 |pages=269–281 |doi=10.1007/s41252-021-00203-z |s2cid=236387901 |issn=2366-7532|doi-access=free }} The shorter version, which has less bias in terms of gender and academic skills, retains questions from the original version such as whether the child will use "outrageous or shocking behavior" to avoid a demand, whether the child's mood changes rapidly, and whether the child is unaware or indifferent to social hierarchies and the role of authority figures. The original questionnaire has been lightly adapted to be more appropriate for adults (EDA-QA).{{Cite journal |last1=Egan |first1=Vincent |last2=Linenberg |first2=Omer |last3=O’Nions |first3=Elizabeth |date=February 2019 |title=The Measurement of Adult Pathological Demand Avoidance Traits |journal=Journal of Autism and Developmental Disorders |language=en |volume=49 |issue=2 |pages=481–494 |doi=10.1007/s10803-018-3722-7 |issn=0162-3257 |pmc=6373319 |pmid=30140985}}

However, the EDA-Q has been criticized for its methodological limitations, particularly its reliance on circular reasoning. PDA research often lacks methodological rigor, with many studies using tools like the EDA-Q, which was developed based on criteria derived from Newson et al.’s (2003) original descriptions rather than independent validation.{{Cite journal |last1=Haire |first1=Lauren |last2=Symonds |first2=Jennifer |last3=Senior |first3=Joyce |last4=D’Urso |first4=Giulio |title=Methods of Studying Pathological Demand Avoidance in Children and Adolescents: A Scoping Review |journal=Frontiers in Education |volume=9 |year=2024 |doi=10.3389/feduc.2024.1230011 |doi-access=free |language=en}}

PDA is typically associated with autism, though a correlation with attention deficit hyperactivity disorder (ADHD) has also been found. Emotional lability and hostility are other traits possibly associated with PDA.{{Cite journal |last1=Egan |first1=Vincent |last2=Bull |first2=Elinor |last3=Trundle |first3=Grace |date=October 2020 |title=Individual differences, ADHD, adult pathological demand avoidance, and delinquency |url=https://www.sciencedirect.com/science/article/abs/pii/S0891422220301633 |journal=Research in Developmental Disabilities |volume=105 |doi=10.1016/j.ridd.2020.103734 |pmid=32682221 |hdl-access=free |hdl=2437/302438}}

One study found that while approximately 20% of autistic individuals exhibited some traits associated with PDA in childhood, only about 4% fully met the criteria for PDA. These findings raise questions regarding whether PDA constitutes a lifelong condition or is primarily a childhood-specific presentation. The study suggests that while PDA may represent a minority subset of ASD diagnoses in childhood, the diagnostic criteria for PDA are unlikely to be consistently met in later adolescence and early adulthood.{{Cite journal |last1=Gillberg |first1=Christopher |last2=Gillberg |first2=I. Carina |last3=Thompson |first3=Lucy |year=2015 |title=Extreme ("pathological") demand avoidance in autism: a general population study in the Faroe Islands |url=https://doi.org/10.1007/s00787-014-0647-3 |journal=European Child & Adolescent Psychiatry |volume=24 |issue=8 |pages=979–984 |doi=10.1007/s00787-014-0647-3 |pmid=25398390 |access-date=2025-01-29|url-access=subscription }}

Commonly associated features of PDA include:

• an appearance of social skills that are superficially acceptable but which have odd features, such as (in children) a belief that the normal rules apply only to other people, or that they have the same authority as adults or people in positions of authority{{cite journal |vauthors=O'Nions E, Gould J, Christie P, Gillberg C, Viding E, Happé F |date=April 2016 |title=Identifying features of 'pathological demand avoidance' using the Diagnostic Interview for Social and Communication Disorders (DISCO) |journal=European Child & Adolescent Psychiatry |volume=25 |issue=4 |pages=407–419 |doi=10.1007/s00787-015-0740-2 |pmc=4820467 |pmid=26224583}}
• emotional lability, such as being affectionate one moment and angry the next, and impulsive and controlling behaviors
• being comfortable with role-playing and pretending to be other characters
• "soft" signs of neurological divergence, such as language delay, obsessive behavior, delayed milestones, or clumsiness

The underlying cause of demand avoidance is unknown. Many individuals identified with PDA also have a co-occurring anxiety disorder, such as generalized anxiety disorder. Research has explored intolerance of uncertainty as a potential contributing factor to PDA, as individuals with PDA may exhibit extreme avoidance behaviors in response to unpredictable situations or demands.{{cite journal | vauthors = Stuart L, Grahame V, Honey E, Freeston M | title = Intolerance of uncertainty and anxiety as explanatory frameworks for extreme demand avoidance in children and adolescents | journal = Child and Adolescent Mental Health | volume = 25 | issue = 2 | pages = 59–67 | date = May 2020 | pmid = 32307839 | doi = 10.1111/camh.12336 | s2cid = 182321645 }} About 40% of autistic people have an anxiety disorder.{{cite journal | vauthors = Zaboski BA, Storch EA | title = Comorbid autism spectrum disorder and anxiety disorders: a brief review | journal = Future Neurology | volume = 13 | issue = 1 | pages = 31–37 | date = February 2018 | pmid = 29379397 | pmc = 5772195 | doi = 10.2217/fnl-2017-0030 }}

Elizabeth Newson investigated PDA as a separate disorder from autism in the 1970s at the Child Development Research Clinic of Nottingham. She proposed it as a pervasive developmental disorder (PDD), but emphasized that it is distinct from autism spectrum disorder, noting that "PDA is a pervasive developmental disorder but not an autistic spectrum disorder; to describe it as such would be like describing every person in a family by the name of one of its members." This perspective reinforces that PDA was not intended to be synonymous with autism from its inception.{{Cite journal |last=Newson |first=E |date=2003-07-01 |title=Pathological demand avoidance syndrome: a necessary distinction within the pervasive developmental disorders : Supporting Information |journal=Archives of Disease in Childhood |language=en |volume=88 |issue=7 |pages=595–600 |doi=10.1136/adc.88.7.595 |issn=0003-9888 |pmc=1763174 |pmid=12818906 |url=https://pmc.ncbi.nlm.nih.gov/articles/instance/1763174/bin/archdisch_archdischild;88_7_595__1.pdf |access-date=2025-02-13}}

When Newson was made professor of developmental psychology at the University of Nottingham in 1994, she dedicated her inaugural lecture to talking about pathological demand avoidance syndrome.{{cite web |date=20 February 2014 |title=Elizabeth Newson obituary |url=https://www.theguardian.com/science/2014/feb/20/elizabeth-newson |access-date=13 December 2020 |work=The Guardian |vauthors=Christie P}}

In 1997, the PDA Society was established in the UK by parents of children with a PDA profile. It became a registered charity in January 2016.{{cite web |title=About the PDA Society |url=https://www.pdasociety.org.uk/about-us-landing/about-us/ |access-date=13 December 2020 |publisher=PDA Society}}

In July 2003, Newson published in Archives of Disease in Childhood for PDA to be recognized as a separate syndrome within the pervasive developmental disorders.{{cite journal |vauthors=Newson E, Le Maréchal K, David C |date=July 2003 |title=Pathological demand avoidance syndrome: a necessary distinction within the pervasive developmental disorders |journal=Archives of Disease in Childhood |publisher=Royal College of Paediatrics and Child Health |volume=88 |issue=7 |pages=595–600 |doi=10.1136/adc.88.7.595 |pmc=1763174 |pmid=12818906}}

In 2020, an incorporated association was established in Australia. Pathological Demand Avoidance Australia, Inc. became a registered charity early 2021.{{cite web |title=PDA Australia |url=https://www.pdaaustralia.org.au |access-date=17 June 2021 |publisher=PDA Australia}}

In March 2020, the first American PDA conference was held. Soon after, PDA North America was formed. It became a registered charity in 2022.{{Cite web |title=PDA North America |url=https://pdanorthamerica.org |website=PDA North America}}

Pathological demand avoidance has been criticized as a name for various reasons, including the negative connotations some confronted with the word pathological might have.{{cite web|url=https://medium.com/neurodiversified/autistic-rational-demand-avoidance-8a5587b86683|title=Autistic PDA: Persistent Drive For Autonomy, by Jillian Enright / neurodiversified|date=22 April 2023 }} For example, autistic social psychologists Damian Milton and Devon Price have suggested the behavior should not be considered pathological. They view PDA as an example of individual autonomy or self-advocacy.

{{cite journal |vauthors=Hess P |date=11 August 2022 |title=Pathological demand avoidance in autism, explained |url=https://www.spectrumnews.org/news/pathological-demand-avoidance-in-autism-explained/ |journal=Spectrum |doi=10.53053/YKGQ6660 |s2cid=251477348 |access-date=2 March 2023|url-access=subscription }}

Alternative names like rational demand avoidance (RDA){{cite book |last=Woods |first=Richard |title=The Routledge International Handbook of Critical Autism Studies |publisher=Routledge |year=2022 |isbn=9781003056577 |editor-last=Milton |editor-first=Damian |editor-link=Damian Milton |location=London |chapter=Rational (Pathological) Demand Avoidance: As a mental disorder and an evolving social construct |doi=10.4324/9781003056577-7 |editor-last2=Ryan |editor-first2=Sara}} or pervasive drive for autonomy{{cite web |last=Butler |first=Emily |date=27 October 2021 |title=Reframing PDA: The Power of an Autistic Perspective |url=https://reframingautism.org.au/reframing-pda-the-power-of-an-autistic-perspective/ |publisher=Reframing Autism}}{{cite web|url=https://www.neurodiverging.com/pda-day-to-day-parenting-pathological-demand-avoidance-pervasive-demand-for-autonomy|title=PDA Day-to-Day: Parenting Pathological Demand Avoidance/ Pervasive Demand for Autonomy / Neurodiverging|date=19 January 2023 }} have been proposed and used.

{{Reflist}}

{{refbegin}}

• {{cite book|title=Collaborative Approaches to Learning for Pupils with PDA: Strategies for Education Professionals| vauthors = Fidler R, Christie P |publisher=Jessica Kingsley Publishers|year=2019|isbn=9781784502614}}
• {{cite web|title=Pathological demand avoidance in autism, explained|url=https://www.spectrumnews.org/news/pathological-demand-avoidance-in-autism-explained/|first=Peter|last=Hess|website=spectrumnews.org|date=2022-08-11|publisher=Simons Foundation}}

{{refend}}

• [https://www.pdasociety.org.uk/resources/helpful-approaches-infographic/ Helpful approaches infographic: PANDA approaches] from PDA Society Resources

{{Pervasive developmental disorders}}{{Authority control}}

Category:Autism