Table of ContentsView AllTable of ContentsPDA: A Trait of Autism?PDA Outside of AutismEffects of PDADiscipline & PDAHow to RespondSkills to BuildProfessional Guidance
Table of ContentsView All
View All
Table of Contents
PDA: A Trait of Autism?
PDA Outside of Autism
Effects of PDA
Discipline & PDA
How to Respond
Skills to Build
Professional Guidance
Pathological demand avoidance (PDA) refers to a profile of behaviors in which a person’s anxiety causes them to avoid everyday demands at an extreme level.PDA is most commonly associated withautismbut may also be related toattention deficit hyperactivity disorder (ADHD), epilepsy, and more.
There is controversy within the medical, autism, andneurodiversecommunities about the validity of PDA. Pathological demand avoidance is not diagnosable because it is not listed in theDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)or theInternational Classification of Diseases, Tenth Revision (ICD-10).
In this article, learn more about pathological demand avoidance in autism, how to cope with these behaviors, and the controversy surrounding this term.
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Neurodivergent vs. NeurotypicalNeurodiversityis the concept that there is a natural spectrum of differences in each human’s brain and that these differences are worth celebrating rather than pathologizing. Neurotypical people have a “normal” brain and behave in ways society expects. In contrast, a neurodivergent individual has brain differences that lead them to behave in ways society doesn’t always expect. Anyone who is diagnosed withautismis neurodivergent.
Neurodivergent vs. Neurotypical
Neurodiversityis the concept that there is a natural spectrum of differences in each human’s brain and that these differences are worth celebrating rather than pathologizing. Neurotypical people have a “normal” brain and behave in ways society expects. In contrast, a neurodivergent individual has brain differences that lead them to behave in ways society doesn’t always expect. Anyone who is diagnosed withautismis neurodivergent.
Pathological Demand Avoidance (PDA): A Trait of Autism?
British psychologist Elizabeth Newson coined the term pathological demand avoidance (PDA) in the 1980s.Newson was working in a mental health clinic with children who had been referred to her because their behavior “reminded” their doctors ofautismbut didn’t quite meet the typical criteria, usually because they were too sociable or imaginative.
The first published mention of PDA was in a 2003 medical journal in which Newson described it as a diagnosis sitting under the umbrella of pervasive developmental disorder.Pervasive developmental disorder is an outdated term that has since been replaced withautism spectrum disorder (ASD)as of the 2013 DSM-5.
Key Features of PDA
In her 2003 article, Newson listed “key features” of PDA that she had observed. Most scientific literature still uses these key features to understand PDA and provide a cohesive definition.You can think of the “key features” as symptoms of PDA, which include:
PDA Controversy
Research on pathological demand avoidance is limited, and the term’s validity continues to spark debates worldwide.
Supporters of PDA argue that labeling these behaviors offers a pathway to faster treatment and a community of others who have had similar experiences. In the United Kingdom, where the concept of PDA originated, diagnostic tools are in development, and the Autism Education Trust, Department of Education, and National Autistic Society now recognize PDA.
Yet, PDA is still not included within the DSM-5 or ICD-10 and lacks international recognition, meaning there is no universal standard for diagnosis.
Some experts argue that PDA is not a subtype of autism; instead, it is a general behavior profile that could be associated with many different conditions.
There is also an argument that this label pathologizes and punishes self-advocacy among individuals with autism.Whereas, from the perspective of an autistic person, avoidance of demands that elicit extreme anxiety is a perfectly rational response rather than “pathological.”
As a result, some autistic scholars have proposed renaming PDA to:
Although PDA is most frequently discussed in the context of autism, it has also been associated with other conditions discussed below.
Ultimately, though, there is a real lack of research on PDA. It is not yet possible to say what conditions PDA is most associated with because PDA has not been thoroughly defined or studied.
ADHD
There are anecdotal reports that PDA is associated withADHD. One study found evidence to support this connection.However, ADHD is also commonly diagnosedalongside autism, so the exact relationship between these three conditions is unclear.
Epilepsy
Epilepsy is another condition connected to PDA, although evidence is limited to low-quality case studies.In her seminal 2003 paper on PDA, Newson mentioned possible neurological involvement and that she observed co-occurring epilepsy in some children with PDA.
Oppositional Defiant Disorder
PDA has also been associated withoppositional defiant disorder (ODD), a condition diagnosed among children who act irritable, argumentative, and defiant.
However, this likely is either a misdiagnosis or an unhelpful way of conceptualizing PDA behaviors.PDA differs from ODD in that the “defiance” stems from overwhelming anxiety and is not willful.
Effects of PDA, With or Without Autism
A person with PDA will avoid ordinary demands and expectations to an extreme level. They use social strategies—such as negotiation, distraction, manipulation, role play, and refusal—to avoid demands.
Examples of “demands” include:
PDA Behaviors and Motivation
But why does someone with PDA refuse to brush their teeth, put on clothes, finish their homework, attend an appointment, show up at work, or participate in their favorite hobbies and activities in the first place?
For many people with PDA, the reason comes down to anxiety and control.People with PDA report that demands—however small—can feel like their sense of control and agency is getting ripped away from them.
This results in high anxiety levels, making them feel “frozen” and unable to comply. They may even say something like, “I can’t; my legs are frozen,” which should be taken literally.
How PDA Feels
For this, it is helpful to hear directly from individuals who identify as having PDA. Below are some ways that people with PDA described their experience to the PDA Society:
How to Approach Discipline in Children With PDA
Traditional parenting and discipline strategies that include strict boundaries and contingency-based rewards or punishments are ineffective for children with PDA.Sometimes, these “normal” strategies worsen the child’s PDA behaviors.
Remember that a child with PDA has an intense need for control, and their refusal to do what you ask may be based on a paralyzing anxiety that they are losing control rather than defiance toward your requests.
Instead, experts recommend adopting a “low demand, low arousal” approach to parenting and discipline.
Some PDA parenting suggestions include:
How to Respond to Adults With PDA
Although much of the existing research on PDA is on children, it’s important to remember that these children grow into adults with PDA. Many of the strategies listed above will remain helpful in responding to adults with PDA.
Mindful Skills to Build With PDA
PDA is a lifelong condition, but there are things you can do to learn to cope with PDA behaviors if you match this profile.
Some skills to build with PDA include:
Attending therapy with a PDA-informed professional, such asacceptance and commitment therapy (ACT), can also help.
Professional Guidance on PDA Disorder
Seeking support for PDA can be challenging because of the controversy and uncertainty surrounding it and because it is not a diagnosable condition included in the DSM-5.
Awareness and requests for PDA diagnosis are growing, particularly in the United Kingdom (where the term originated and most of its research is performed).In the United States, PDA awareness is much lower.
If you suspect that you or someone you care for has PDA, seek help from a PDA-informed clinician, educator, or social services professional. The PDA Society provides guidance and information sheets for professionals who want to learn more about the PDA profile.
More resources on PDA include:
Summary
PDA is a controversial term that refers to a profile of behaviors sometimes seen in individuals with autism. People with PDA avoid demands to an extreme extent and use social strategies like distraction, refusal, role-playing, evasion, and more to help with this avoidance. It is challenging to receive an official diagnosis because it is not an officially recognized condition. However, resources are available to learn more about PDA and coping strategies you can try to manage its associated behaviors.
15 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.National Autistic Society.PDA—a guide for autistic adults.Harvard Health Publishing.What is neurodiversity?Newson E, Maréchal KL, David C.Pathological demand avoidance syndrome: a necessary distinction within the pervasive developmental disorders.Archives of Disease in Childhood. 2003;88(7):595-600. doi: 10.1136/adc.88.7.595Kildahl AN, Helverschou SB, Rysstad AL, et al.Pathological demand avoidance in children and adolescents: a systematic review.Autism. 2021;25(8):2162-2176. doi: 10.1177/13623613211034382PDA Society.Identifying and assessing PDA.Moore A.Pathological demand avoidance: What and who are being pathologised and in whose interests?Global Studies of Childhood. 2020;10(1):39-52. doi: 10.1177/2043610619890070Green J, Absoud M, Grahame V, et al.Pathological demand avoidance: symptoms but not a syndrome.The Lancet Child & Adolescent Health. 2018;2(6):455-464. doi:10.1016/S2352-4642(18)30044-0Kamp-Becker I, Schu U, Stroth S.Pathological demand avoidance: current state of research and critical discussion.Z Kinder Jugendpsychiatr Psychother. 2023;51(4):321-332. doi:10.1024/1422-4917/a000927Egan V, Bull E, Trundle G.Individual differences, ADHD, adult pathological demand avoidance, and delinquency.Research in Developmental Disabilities. 2020;105:103733. doi:10.1016/j.ridd.2020.103733Reilly C, Atkinson P, Menlove L, et al.Pathological demand avoidance in a population-based cohort of children with epilepsy: four case studies.Research in Developmental Disabilities. 2014;35(12):3236-3244. doi:10.1016/j.ridd.2014.08.005O’Nions E, Eaton J.Extreme/‘pathological’ demand avoidance: an overview.Paediatrics and Child Health. 2020;30(12):411-415. doi:10.1016/j.paed.2020.09.002PDA Society.What is demand avoidance?PDA Society.How PDA can feel.PDA Society.Self-help, coping strategies, and therapies for adult PDAers.PDA Society.Working with PDA.
15 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.National Autistic Society.PDA—a guide for autistic adults.Harvard Health Publishing.What is neurodiversity?Newson E, Maréchal KL, David C.Pathological demand avoidance syndrome: a necessary distinction within the pervasive developmental disorders.Archives of Disease in Childhood. 2003;88(7):595-600. doi: 10.1136/adc.88.7.595Kildahl AN, Helverschou SB, Rysstad AL, et al.Pathological demand avoidance in children and adolescents: a systematic review.Autism. 2021;25(8):2162-2176. doi: 10.1177/13623613211034382PDA Society.Identifying and assessing PDA.Moore A.Pathological demand avoidance: What and who are being pathologised and in whose interests?Global Studies of Childhood. 2020;10(1):39-52. doi: 10.1177/2043610619890070Green J, Absoud M, Grahame V, et al.Pathological demand avoidance: symptoms but not a syndrome.The Lancet Child & Adolescent Health. 2018;2(6):455-464. doi:10.1016/S2352-4642(18)30044-0Kamp-Becker I, Schu U, Stroth S.Pathological demand avoidance: current state of research and critical discussion.Z Kinder Jugendpsychiatr Psychother. 2023;51(4):321-332. doi:10.1024/1422-4917/a000927Egan V, Bull E, Trundle G.Individual differences, ADHD, adult pathological demand avoidance, and delinquency.Research in Developmental Disabilities. 2020;105:103733. doi:10.1016/j.ridd.2020.103733Reilly C, Atkinson P, Menlove L, et al.Pathological demand avoidance in a population-based cohort of children with epilepsy: four case studies.Research in Developmental Disabilities. 2014;35(12):3236-3244. doi:10.1016/j.ridd.2014.08.005O’Nions E, Eaton J.Extreme/‘pathological’ demand avoidance: an overview.Paediatrics and Child Health. 2020;30(12):411-415. doi:10.1016/j.paed.2020.09.002PDA Society.What is demand avoidance?PDA Society.How PDA can feel.PDA Society.Self-help, coping strategies, and therapies for adult PDAers.PDA Society.Working with PDA.
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
National Autistic Society.PDA—a guide for autistic adults.Harvard Health Publishing.What is neurodiversity?Newson E, Maréchal KL, David C.Pathological demand avoidance syndrome: a necessary distinction within the pervasive developmental disorders.Archives of Disease in Childhood. 2003;88(7):595-600. doi: 10.1136/adc.88.7.595Kildahl AN, Helverschou SB, Rysstad AL, et al.Pathological demand avoidance in children and adolescents: a systematic review.Autism. 2021;25(8):2162-2176. doi: 10.1177/13623613211034382PDA Society.Identifying and assessing PDA.Moore A.Pathological demand avoidance: What and who are being pathologised and in whose interests?Global Studies of Childhood. 2020;10(1):39-52. doi: 10.1177/2043610619890070Green J, Absoud M, Grahame V, et al.Pathological demand avoidance: symptoms but not a syndrome.The Lancet Child & Adolescent Health. 2018;2(6):455-464. doi:10.1016/S2352-4642(18)30044-0Kamp-Becker I, Schu U, Stroth S.Pathological demand avoidance: current state of research and critical discussion.Z Kinder Jugendpsychiatr Psychother. 2023;51(4):321-332. doi:10.1024/1422-4917/a000927Egan V, Bull E, Trundle G.Individual differences, ADHD, adult pathological demand avoidance, and delinquency.Research in Developmental Disabilities. 2020;105:103733. doi:10.1016/j.ridd.2020.103733Reilly C, Atkinson P, Menlove L, et al.Pathological demand avoidance in a population-based cohort of children with epilepsy: four case studies.Research in Developmental Disabilities. 2014;35(12):3236-3244. doi:10.1016/j.ridd.2014.08.005O’Nions E, Eaton J.Extreme/‘pathological’ demand avoidance: an overview.Paediatrics and Child Health. 2020;30(12):411-415. doi:10.1016/j.paed.2020.09.002PDA Society.What is demand avoidance?PDA Society.How PDA can feel.PDA Society.Self-help, coping strategies, and therapies for adult PDAers.PDA Society.Working with PDA.
National Autistic Society.PDA—a guide for autistic adults.
Harvard Health Publishing.What is neurodiversity?
Newson E, Maréchal KL, David C.Pathological demand avoidance syndrome: a necessary distinction within the pervasive developmental disorders.Archives of Disease in Childhood. 2003;88(7):595-600. doi: 10.1136/adc.88.7.595
Kildahl AN, Helverschou SB, Rysstad AL, et al.Pathological demand avoidance in children and adolescents: a systematic review.Autism. 2021;25(8):2162-2176. doi: 10.1177/13623613211034382
PDA Society.Identifying and assessing PDA.
Moore A.Pathological demand avoidance: What and who are being pathologised and in whose interests?Global Studies of Childhood. 2020;10(1):39-52. doi: 10.1177/2043610619890070
Green J, Absoud M, Grahame V, et al.Pathological demand avoidance: symptoms but not a syndrome.The Lancet Child & Adolescent Health. 2018;2(6):455-464. doi:10.1016/S2352-4642(18)30044-0
Kamp-Becker I, Schu U, Stroth S.Pathological demand avoidance: current state of research and critical discussion.Z Kinder Jugendpsychiatr Psychother. 2023;51(4):321-332. doi:10.1024/1422-4917/a000927
Egan V, Bull E, Trundle G.Individual differences, ADHD, adult pathological demand avoidance, and delinquency.Research in Developmental Disabilities. 2020;105:103733. doi:10.1016/j.ridd.2020.103733
Reilly C, Atkinson P, Menlove L, et al.Pathological demand avoidance in a population-based cohort of children with epilepsy: four case studies.Research in Developmental Disabilities. 2014;35(12):3236-3244. doi:10.1016/j.ridd.2014.08.005
O’Nions E, Eaton J.Extreme/‘pathological’ demand avoidance: an overview.Paediatrics and Child Health. 2020;30(12):411-415. doi:10.1016/j.paed.2020.09.002
PDA Society.What is demand avoidance?
PDA Society.How PDA can feel.
PDA Society.Self-help, coping strategies, and therapies for adult PDAers.
PDA Society.Working with PDA.
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