What is Pathological Demand Avoidance (PDA)?
Over the last several months, I have received an increasing number of inquiries about a condition called Pathological Demand Avoidance (PDA for short). Since PDA is a relatively new concept, there seems to be a lot of confusion as to what it is and how it is “diagnosed.” In today’s post, I want to examine the origins of PDA, its clinical features, and how to identify and treat PDA.
The History of Pathological Demand Avoidance
In the early 1970s, researchers in England first developed the concept of pathological demand avoidance. Interestingly, the majority of children who participated in the research studies were described as “atypical” and exhibited traits associated with autism. However, many of them did not meet the full diagnostic criteria of autism, so the researchers began exploring alternative explanations for their behaviors and the idea of PDA was born.
Over the ensuing decades, PDA continued to gain recognition in the clinical community, particularly in the UK, as further research lent validity to and acceptance of this condition. In 1997, the PDA Society was established in the UK as a resource for parents of children with PDA traits. And in 2020, the first PDA conference in the United States was held, which led to the formation of PDA North America.
Presently, Pathological Demand Avoidance is a widely recognized condition throughout the world. However, despite is acceptance, very little is known or understood about this condition.
What are Symptoms of PDA?
According to the PDA Society, which is the widely-recognized authority on PDA, key features of PDA include:
Resistance and avoidance of ordinary demands of life
Use of social strategies as part of the avoidance
Appearing sociable on the surface, but lacking depth in understanding
Experiencing excessive mood swings and impulsivity
“Obsessive” behavior, often focused on other people
Appearing comfortable in role play, sometimes to an extreme extent
Demand Avoidance
The most common and necessary trait when considering PDA is “demand avoidance.” Demand avoidance involves the ordinary demands of one’s life or environment. For example, individuals with PDA resist making and attending doctor appointments, engaging in everyday activities like brushing teeth and getting dressed, and other important obligations like getting to school every day.
Additionally, individuals with PDA avoid activities simply because they are expected to attend or complete them; they do not tend to avoid activities for any other reason, such as difficulty or disinterest in the activity itself. Often times when a child with PDA is asked to do a required activity, his or her sense of control may feel threatened and cause elevated anxiety. This is why individuals with PDA are often viewed as having a need for control.
The PDA Society also makes clear that PDA falls on a spectrum, meaning symptoms present differently and to a varying degree in different people. Some of the most common symptoms and behaviors of individuals experiencing PDA include:
Giving excuses (“I can’t clean my room because my legs don’t work!”)
Flight responses (running away or self-sabotage)
Rigid or inflexible play with others
Emotion dysregulation
Obsessive behavior, especially over other people (e.g., a “best” friend)
Is PDA a Diagnosable Condition?
Most clinicians in the United States, myself included, use the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) when making diagnoses. In the most current edition of the DSM, Pathological Demand Avoidance is NOT a recognized disorder. Additionally, despite being widely-recognized in the UK, PDA is not a diagnosable condition there either.
Are PDA and Autism the Same Thing?
As mentioned earlier in this post, PDA’s roots are directly tied to autism, as many of the initial test subjects displayed characteristics of autism. As research has evolved, it is evident that PDA is understood to be a profile on the autism spectrum. As the PDA Society notes, “a PDA profile of autism means that individuals share autistic characteristics.” However, it is important to understand that PDA and autism are not interchangeable terms.
Individuals who are not autistic can have a PDA profile.
Assessment and Treatment for PDA
As with any suspected condition, working with a qualified clinician is critical to identifying PDA. Typically, an evaluation for autism will uncover characteristics of PDA. Usually this will involve a clinical consultation with the individual and his or her caretaker, formal assessments that allow for observations and quantitative data, parent/teacher/and self-report measures to gauge the individual’s functioning in multiple settings, and often times classroom or home observations.
Treatment and support for PDA is also similar to treatment and support for autism. The main form of support involves behavior and environmental modifications to assist with flexibility and interpersonal communication. Students who experience PDA will often benefit from and IEP at school as well. Early identification and intervention is key to successful development.