Conversations about Pathological Demand Avoidance (PDA) have come to the forefront of social media, especially for caregivers who have children that consistently are non-compliant with demands and may have been diagnosed with autism spectrum disorder (ASD), Oppositional Defiant Disorder (ODD), or Attention-Deficit Hyperactivity Disorder. While PDA has become a hot topic, it is not defined or recognized as a mental health diagnosis on its own. So, what is it?
Instead, PDA is defined as a distinct behavioral profile within the autism spectrum “characterized by extreme resistance to everyday demands, driven by an anxiety-based need to control” (Newson, Le Maréchal, & David, 2003). PDA is understood as a specific presentation within the autism spectrum, where children and teens exhibit defining features, including: obsessive avoidance of ordinary demands, surface level abilities to be social that may mask misunderstanding of social hierarchies, mood impulsivity characterized by sudden shifts between expressions of aggression and affection, a tendency to role-play or pretend as a strategy for avoiding demands, exhibiting controlling behavioral towards peers and adults, and extreme outbursts when perceived control is lost as a result of pressure to comply with demands. Overall, PDA is best understood as a behavioral profile, most commonly in individuals on the autism spectrum, where the child or teen consistently and creatively avoids demands, and this is primarily driven by anxiety.
Even though we have this working definition, the conceptualization of PDA remains controversial and poorly defined, especially when applied to individuals who are not on the autism spectrum. More research is needed to clearly understand whether the traits of PDA represent a separate condition, or if it is truly a behavioral pattern linked to anxiety within autism.
Children with diagnoses of ODD and ADHD may also frequently seem to avoid commands given by adults and peers, and it makes sense to wonder whether PDA may play a role in this avoidance.
The diagnosis of ODD is a behavioral disorder characterized by a persistent pattern of angry or irritable mood, argumentative or defiant behavior, and vindictiveness. Children with ODD often intentionally annoy others, blame others for their mistakes, and deliberately defy demands. While there is similarity in resisting demands for those who fit in the PDA profile, the major difference is that demand avoidance is not driven by anxiety in kids with ODD. The motivation for ignoring demands for a kid with ODD is to defy the person in an authority often in a power struggle driven by anger, frustration, or the desire to control the situation. Often, this shows up as an overt defiance through statements and behaviors. If a child fits into the PDA trait profile, the primary driver of demand avoidance would be anxiety, and their avoidance would look like manipulating the situation with surface level social skills to get out of completing demands.
Kids with ADHD may also refuse to comply with demands at times, but just like with ODD, the underlying drivers for avoidance or non-compliance are different. A kid with ADHD might avoid doing the things they are asked, or may appear resistant, like a kid who fits into the PDA profile. Although, for a child with ADHD, avoidance is most often a secondary effect of difficulty with attention on tasks that they perceive as being boring, difficult, or overwhelming. For kids with ADHD, task initiation is a huge barrier, especially if there is something else more engaging for them that they could do, like continuing to play with their toys. Most times, anxiety does not play a major role in task or demand avoidance for kids with ADHD, but it does in kids with PDA.
We often expect that more anxious children will express it by being withdrawn, quiet, or acting scared. But for some anxious kids, anxiety can be expressed in a very external way. When a child is anxious about changing plans, or not having control, they may express demand avoidance that is unexpected for a child who is feeling scared. But even though the resulting behavior of this anxiety is different, we still use exposure-based approaches to help the child overcome the underlying fear that is driving the avoidance.
Overall, while the behavioral outcomes in response to demands may look similar for kids, the distinction is important to note for treatment providers and caregivers, because the underlying motivation for the behavior is what becomes most effective to target. Understanding your child and why they are refusing demands can help tailor intervention strategies. That being said, some of the same interventions recommended for ADHD and ODD can still be effective for children who seem to fit the PDA profile.
For example, PCIT is a gold-standard intervention for children between the ages of 2 and 7 and is understood by professionals as a great technique for kids with PDA too, regardless of whether the PDA is driven by autism, anxiety, ODD, or ADHD. In PCIT, caregivers learn how to give effective commands, praise children for the behavior that they would like to see and create structure in the home. The treatment begins with a child-directed interaction phase, where caregivers practice the warmth skills to build a greater bond with their child. Then, the parent-directed interaction phase follows, where caregivers practice giving commands, praise compliance, and use safe and consistent consequences when faced with non-compliance.
If we consider PDA to be an anxiety response, we know from a large evidence-base that the best treatment for anxiety is exposure. Within the parent-directed interaction phase of PCIT, children will be safely exposed to demands and will be met with the same consistent response from caregivers, effectively reducing anxiety responses with further practice. It is effective because it allows for predictability, the caregiver response is always the same to non-compliance, and the structure allows for gradual exposure from simple commands (ex: hand me that block) to more complex commands (ex: put the toys into the red bin). Another key feature is that caregivers are encouraged to give commands only when it is necessary to increase the chances of compliance.
Many times, we give kids command, after command, after command. If a child experiences intense anxiety when given a command, it makes sense for them to be avoidant of these interactions, especially when they happen all the time. In place of giving many commands, caregivers are encouraged to give choices, when possible, which can help a child who struggles with anxiety feel like they have more control over their environment. And, when commands are given in an effective manner, over time and with repeated practice, kids will learn how to tolerate and accept commands.