What Is Pathological Demand Avoidance (PDA)?
Pathological demand avoidance is a neurodevelopmental difference that affects how people perceive requests from others. This avoidance is described as “pathological” because it can go to extremes and interfere with a person’s daily life activities, social interaction, family relationships, school and employment settings.
While we can all avoid demands to a certain extent in everyday life, people with pathological demand disorder consistently avoid and refuse demands. While PDA is not listed in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, many experts associate the PDA profile with Autism Spectrum Disorder or attention deficit hyperactivity disorder (ADHD).
The key characteristics of PDA include:
- Persisting need to resist ordinary demands and requests
- Resistance as a mechanism to cope with anxiety
- Children may use different social strategies to avoid demands which reflect functional and logical reactions
Often, people tend to perceive individuals with PDA as antagonistic and rebellious. However, it’s essential to note that pathological demand avoidance is not a choice, and people with PDA may often reject doing things they find interesting, such as favourite activities and hobbies. In more severe cases, PDA may affect a person’s hygiene and eating habits, which can be a potential health risk.
Signs of Pathological Demand Avoidance (PDA)
When forced to comply, some people with PDA can exhibit challenging behaviour or experience panic attacks. Sings of pathological demand avoidance can be noted from a very young age and usually manifest with:
- Passive early history: Children may be prone to dropping toys and just watching. With age, they might become 'actively passive' and avoid ordinary demands.
- Obsessive demand avoidance: Avoiding demands due to enormous pressure from ordinary expectations.
- Making excuses: People with pathological demand avoidance may use many different excuses to avoid complying with demands. This may include different types of verbal distraction, persistent change of conversation topic, and purposefully using gestures.
- Frequent mood swings: Mood swings sometimes go to extremes, often changing suddenly, especially when requested to do something.
- Surface social communication: Children and adults with PDA possess good social and communication skills. However, they experience challenges in forming emotional bonds with other people and face difficulties with social rules.
- Obsessive behaviour: Obsessive behaviours can vary, but mainly involves obsessions with people rather than objects or routines.
It’s important to remember that every individual with PDA presents with different behaviours and characteristics. If you believe someone has a pathological demand disorder, it is crucial to seek evaluation and support from qualified professionals, such as psychologists, psychiatrists, or developmental specialists. An accurate assessment can help understand an individual’s unique needs and provide appropriate interventions and support.
Pathological Demand Avoidance in Children
Demand resistance, to a certain extent, is a typical feature for children, especially for toddlers. In some cases, this can go to extremes, and some children avoid or resist anything they perceive as a demand. This extreme demand avoidance often interferes with the child’s functioning at school, at home, and with peers.
Pathological demand avoidance can be challenging for parents and teachers as children with PDA often refuse to do tasks like:
- Putting on shoes
- Getting dressed
- Sitting down in the classroom
- Saying the names of objects
- Completing school and homework tasks
To others, this behaviour seems like wilful defiance, but this is a common misconception. Children with PDA tend to avoid demands as a result of internal anxiety and a lack of flexibility and adjusting skills. They may even avoid doing things for themselves if the activity causes them internal discomfort that will result in avoidance.
Avoidance can take many forms, including refocusing on something else, making excuses, withdrawing and creating a distraction. Many experts suggest that PDA is commonly seen in Autistic children. However, not every person with pathological demand avoidance has an Autism diagnosis.
Pathological Demand Avoidance in Adults
PDA is believed to be present from early childhood but can continue to adulthood. However, it’s essential to note that research on PDA in adults is limited, and understanding PDA in adulthood is still evolving. However, people assessed with PDA traits share one crucial characteristic – avoiding everyday demands.
Characteristics of PDA in adults may include:
- Demand avoidance: Adults may have a strong need to avoid demands and requests, finding them overwhelming and anxiety-provoking. They may use avoidance strategies, such as distraction, negotiation, or defiance, to escape tasks or responsibilities.
- High anxiety levels: Anxiety is a common feature of PDA, and adults with this profile may experience intense anxiety when faced with demands or unpredictable situations.
- Social difficulties: Difficulties in social communication and interaction are typical of PDA, which can impact relationships with peers, family, and colleagues.
- Sensory sensitivities: Like many individuals with Autistic Spectrum Disorder, adults with PDA may experience sensory sensitivities to stimuli such as noise, light and textures.
- Difficulty with change: PDA is often associated with a need for control and difficulty in accepting changes in routines or plans.
- Masking symptoms: Some adults with PDA may have developed strategies to mask their difficulties in social situations, which can be physically and emotionally draining.
Causes for PDA
The specific causes of PDA still need to be fully understood. However, research suggests that a combination of genetic, environmental, and neurological factors may contribute to the development of PDA. Some potential causes and contributing factors may include:
- Genetic factors: Evidence suggests that Autism, including PDA, can have a genetic basis. Research has identified various genetic variations that may increase the risk of Autism Spectrum Disorders, including PDA. However, it is important to note that no single gene has been identified as the sole cause of Autism or PDA.
- Neurological differences: Studies using brain imaging techniques have found differences in the brain structure and function of individuals with Autism. These differences might be related to difficulties in processing information, sensory sensitivities, and difficulties in understanding and responding to social cues.
- Environmental factors: Some environmental factors may also play a role in the development of PDA. These factors could include prenatal exposures (e.g., maternal infections during pregnancy or early life stressors).
- Early developmental challenges: Difficulties in early development, such as delays in language or social skills, might contribute to the development of PDA. Early communication and social interaction challenges can lead to increased anxiety and avoidance behaviours.
- Co-occurring conditions: People with PDA often have co-occurring challenges, such as anxiety disorders, obsessive-compulsive disorder (OCD), attention-deficit hyperactivity disorder (ADHD), or sensory processing difficulties. These additional challenges can interact with and exacerbate PDA.
PDA Assessment
As PDA is not listed in the DSM-5 TR or the International Classification of Diseases 10th Revision (ICD-10), there are no universal diagnostic criteria for pathological demand avoidance. However, recently a multidisciplinary group of professional and experienced medical experts working in the NHS and private practice compiled a document to aid the assessment of the PDA profile.
The purpose of the paper is to help distinguish PDA from other related behavioural patterns and provide adequate support and guidance for people and families. Additionally, a team of professionals in psychology, behavioural therapy and other related fields, along with the person’s family, will cooperate to provide an accurate assessment. The process may include family history and behaviour observations.
Strategies for Supporting Individuals with PDA
Strategies for supporting individuals with rational demand avoidance should be personalised, and focused on building flexibility and adaptive skills through motivation. For example, a child with a PDA profile may struggle with receiving direct communication about demands, which can cause acute anxiety and avoidance.
Leaf Complex Care implements unique and individualised strategies for every person with PDA. Our skilled teams use a person-centred and collaborative approach with negotiation skills to help the individual feel more in control. The goal is to build flexibility and adaptive skills through motivation and a more intuitive approach.
A great example of building flexibility and reducing demand anxiety in children with PDA is through using more progressive language such as ‘If you’re happy to’ or ‘When you have finished with…. could you…’. This can help individuals reduce their anxiety levels and avoid demand avoidance behaviours.
However, every person is unique, with their own strengths and needs. Therefore, the best strategy to support your loved one with a PDA should be determined by experienced healthcare professionals, along with constant emotional support and human-centred approaches.
PDA Awareness and Education
PDA can often be misdiagnosed as oppositional defiant disorder (ODD) or conduct disorder due to similarities in behavioural presentations. Proper education can help distinguish PDA from other conditions and lead to more accurate diagnoses.
Education about PDA empowers families to seek appropriate assistance and support, empowering them to better manage the challenges that may arise in daily life.
PDA awareness helps reduce the stigma associated with pathological demand avoidance and other neurodevelopmental differences. Increased knowledge promotes empathy and understanding, creating a more inclusive and supportive environment for individuals with PDA and their families.
Leaf Complex Care Applies a Person-Centred Care Approach for Supporting Individuals with Complex Needs
At Leaf Complex Care, we are committed to providing holistic and person-centred care to every individual we support. Our mission is to empower people with complex care needs to accept their difference and leverage their skills and talents to reach their full potential.
We believe every individual deserves a place in the community, with equal education and working opportunities. We strive to empower people to develop their strengths, skills and talents and be fellow members of the community.
We celebrate neurodiversity in every action and interaction, and seeing people smile is our driving force.
If you are looking for a reliable and professional care provider, Lead Complex Care is the right choice for you. We provide CQC-regulated care in Bristol, Slough, Somerset and the Midlands.
Contact us, and we will design a tailored, humanised care plan for you or your loved one.
