What is “demand avoidance” and when is it pathological?
We all experience “demand avoidance” at times, i.e. we resist doing something which is either requested of us or expected of us. This article sets out to raise awareness of and explore a specific “condition” or profile which has been identified in the field of Psychology but about which there is still some controversy and lack of understanding. The focus here is on children. Recommended strategies to support PDA sufferers, both at home and in education, are also outlined.
Demand Avoidance in People with ASD
People with Autism Spectrum Disorder (ASD) sometimes avoid situations which cause them anxiety or give them sensory overload as well as activities which are not in their usual routine. They also sometimes resist transitioning from one activity to another or avoid activities which seem pointless to them. They may refuse, have an emotional crisis or try and “escape”.
How does Pathological Demand Avoidance differ from the above?
Individuals with PDA might avoid the above situations for the same reasons. However, PDA has some unique aspects:
- Many everyday demands are avoided simply because they are demands. It is the expectation (from someone else or yourself) which leads to a feeling of lack of control, and this feeling triggers anxiety increases and even panic.
- There can be an ‘irrational quality’ to the avoidance – for instance, a seemingly dramatic reaction to a tiny request, or the feeling of hunger inexplicably stopping someone from being able to eat.
- The avoidance can vary, depending on an individual’s capacity for demands at the time, their level of anxiety, their overall health/well-being or the environment (people, places and things).
What kind of everyday demands are we talking about?
- A direct demand (an instruction like “brush your teeth!” or “put your coat on!” or “do your homework!”).
- An internal demand (e.g. willing yourself to do something or bodily needs, e.g. the need to eat when you are hungry).
- An indirect or implied demand (including any expectation, for example a question that requires an answer, food that you are expected to eat, or a bill that needs to be paid.
Conversely, a demand that triggers stress or anxiety in individuals with PDA is not necessarily something unpleasant: it could be, for instance, opening your presents on your birthday.
When was the PDA profile first identified?
The term was originally coined by Elizabeth Newson in the 1980s but it took until 2003 for it to appear in formal scientific research (Newson et al., Arch Dis Child 88:595–600, 2003). Originally, PDA was a term used to describe a group of children who did not fit into the stereotypical presentation of autism recognised at that time but who shared certain characteristics with each other, the key one being a persistent and marked resistance to demands. According to Newson, autistic children display rigidity through rules, routine and predictability; in PDA their rigidity is in their need to avoid demands and control situations, which can often lead to the child appearing extremely impulsive in their emotions and behaviour, as they react to what they perceive to be demands.
Whilst autistic children often show little or no sociability, children with PDA display surface sociability. However, they often fail to recognise boundaries and struggle to understand the social norms of relationships. Children with PDA, like autistic children, often experience early language delay but often catch up later. They might have normal facial expressions and make eye contact; however their speech content can seem odd and, importantly, communication can be significantly affected by demand avoidance. The predominant characteristic of children with PDA is their continued resistance and avoidance of the ordinary demands of life. Whilst autistic children can be reluctant to comply, this is often in a non-social way; they lack the empathy to make excuses or develop strategies for avoidance. In contrast, children with PDA develop multiple strategies of avoidance, which they are able to adapt to the adult involved and can appear socially manipulative. (Newson, 2000).
Outside the UK, there is little awareness of PDA. However, in the UK, the term has been given some attention in TV and social media and this has led to an increase in pressure to consider PDA as a diagnosable disorder. Currently, while PDA is mentioned in latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) it is treated as a specific profile under the umbrella diagnosis of autism spectrum disorders (ASD). However, this does not mean that clinicians cannot use PDA as a descriptive diagnosis alongside a clinical diagnosis of ASD.
How common is PDA?
We don’t know. Because demand avoidance is currently understood as one characteristic in a person’s neurodevelopmental profile and is neither a diagnosable stand-alone condition nor is there a standardised assessment for the characteristic, there are no data to reliably indicate how common it may be. Research to date has been limited and often unreliable.
“Can’t” versus “won’t”: the difference between PDA and Oppositional Defiant Disorder
It is without doubt very stressful for parents to experience their child avoiding simple tasks or refusing to follow rules or basic routines. However, it is essential that we distinguish between PDA (Pathological Demand Avoidance) and ODD (Oppositional Defiant Disorder). Whereas PDA is an anxiety-driven need to be in control and avoid demands or expectations, ODD is characterised by angry and irritable mood, an argumentative and defiant attitude and vindictiveness.
Accurately identifying whether a child has PDA or ODD is key for implementing the right support strategies and can help others outside the immediate family to better understand the child’s needs. Some key characteristics of PDA which can help us with this distinction are:
- Difficulty tolerating uncertainty or unpredictability;
- Language delay and trouble with social interaction, which is common among autistic children;
- Mood swings and emotional dysregulation;
- Impulsivity and risk-taking behaviors;
- Obsessions and compulsions related to control or avoidance.
Tactics PDA children might use include distraction, making excuses, or shifting blame to avoid tasks and maintain a sense of control over their surroundings. Understanding these coping mechanisms is crucial for designing effective strategies to support them in managing their anxiety-driven behaviours.
How might a PDA child behave in a school environment?
It is possible that approaches used by teaching or special needs staff for autistic children can be ineffective for a PDA child and might even make things more difficult. In a school setting:
- They may have poor self-esteem, although this might not be obvious from their behaviour.
- Like many young people with ASD, they may behave very differently at home and school due to masking
- They may find regulating their emotions very challenging.
- A PDA learner may not seem interested in ‘doing well’ and may respond negatively to praise, for example by destroying work.
- They may say that the work is boring, or that they already know it.
- They may use charm, imaginative talk or attempt to shock to avoid demands.
- They are likely to want to build friendships with peers, but may find maintaining friendships difficult due to a need for control.
In terms of school attendance:
- They may have experienced school exclusions, even from an early age.
- A PDA child or young person may be absent from school altogether. 70% of PDA learners are either not in school or regularly struggle to attend. Many PDA children are home educated.
- Not every PDA child will have attendance difficulties – some may have slipped under the radar completely.
Support strategies for Parents at home
Unfortunately, there is limited research on support strategies. However, it is evident that people with PDA are best supported with strategies and approaches personalised to their specific strengths and needs.
The following advice is compiled from an American organisation called Trails Carolina (Trails Carolina – Leading Wilderness Therapy For Teens and Adolescents) and the Autism Society, U.K.:
- reduce and/or remove demands whenever possible;
- a collaborative approach is likely to work best, where the child is treated as an equal, rather than adults acting as an authority;
- use indirect communication styles (rather than making demands directly)
- avoid potential stressors such as eye contact, touch and confrontational postures/physical stances;
- if the child is distressed, give them space, remove spectators or move the child to a quiet space if possible;
- a coordinated approach to support is essential, involving the child, their family, school and health or social care professionals;
- In addition, it has been suggested that people with PDA may benefit from:
- identifying and understanding their demand avoidance and its triggers;
- sensory regulation and creating a sensory environment that works for them;
- therapy, counselling, mindfulness and meditation.
Support Strategies for School or Education
- Focus initially on building relationships and trust with a key adult before learning is attempted.
- Focus on the end goal rather than the means of getting there.
- Collaborate with the learner, adopting a child-centred approach focusing on their needs and strengths, and negotiating with them.
- Allow PDA learners to follow their interests and passions, and ensure learning topics are useful, meaningful and relevant to their lives.
- Provide choices and options over what work is completed, when, where, how and with whom.
- Try to recognise any signs of escalation of stress or anxiety and address them before the student reaches crisis point. Distress is usually caused by emotional, social or sensory overload; be aware of the child or young person’s potential triggers.
- Avoid direct requests; use a tone of voice and phrasing so that requests are made indirectly and allow for flexibility.
- Keep expectations to a minimum so that you can focus on the ones that are really important. This may mean having to be flexible about, for example, uniform, timetabling, homework expectations and the way results and progress are recorded.
- Provide a quiet area such as a calm corner for learners to use when they feel overwhelmed.
Some of these approaches may require significant adjustments on the part of the school, but they could be essential in ensuring that a PDA child continues to attend school.
The ongoing debate about PDA
Finally, it is necessary to highlight that, within the autism community (which includes autistic people and their families, autism researchers, health care professionals and education professionals) there is a great deal of disagreement about the validity and usefulness of the concept of PDA. However, one point on which there is broad agreement is that more and better research into Pathological Demand Avoidance is required.
Resources on PDA for Teachers and Parents
- Twinkl has partnered with the PDA Society to provide some helpful guidance documents (PDA PANDA Approach: Disguise and Manage Demands | Twinkl)
- The Autism Society (Demand avoidance (autism.org.uk). This page includes some real-life experiences in the form of quotes.
Abouth the author
Julia Jakubovics is from the UK. She has lived in Spain for over 20 years. She has a degree in Psychology and recently completed a Masters course in Interventions for Learning Difficulties in Children at ISEP (Instituto Superior de Estudios Psicológicos). She is currently working as a Shadow Teacher and Study Coach for Sinews, providing one-to-one and in-class support for children with special education needs.
Sinews MTI
Psychology, Psychiatry and Speech Therapy