Demand Avoidance: ADHD And Pathological Demand Avoidance (PDA)
Young people may frequently resist demands from authority figures. Children may be confused or upset when they believe their autonomy is being threatened—concerns that may be heightened if they live with attention-deficit hyperactivity disorder (ADHD). In some cases, though, a heightened propensity to not comply with requests or commands may rise to the level of pathological demand avoidance (PDA).
Pathological demand avoidance, which typically arises out of developmental disorders, can create further complications in the lives of a child with ADHD and their parents. Below, explore an overview of pathological demand avoidance, its symptoms, and strategies for addressing PDA in children with ADHD.
An overview of pathological demand avoidance (PDA)
Pathological demand avoidance involves extreme avoidance behaviors in response to everyday demands. Also called extreme demand avoidance, PDA lacks universal diagnostic criteria and isn’t mentioned in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Instead, it is a symptom of certain disorders, such as attention-deficit hyperactivity disorder, autism spectrum disorder (ASD), and oppositional defiant disorder (ODD).
Pathological demand avoidance was originally conceptualized as a form of autism. However, as society’s understanding of the dimensional nature of autism evolved, PDA started to be considered one profile (of many) of autism spectrum disorder. During this time, researchers also uncovered the strong links between ASD and ADHD, one of which is the existence of demand avoidance.
PDA can create serious complications in the life of a child with ADHD, potentially exacerbating impairments in everyday functioning and emotional regulation. Additionally, because ADHD and ASD are typically lifelong disorders, adolescent and adult pathological demand avoidance can also be a concern. Despite these challenges, PDA can be managed through treatment and effective parenting strategies.
Symptoms of pathological demand avoidance (PDA)
Additionally, the response will often be out of proportion to the demand. The impulse to resist requests and commands can occur in various situations. Children with PDA may exhibit avoidance behavior when faced with a direct demand (e.g., being asked to clean their room), an internal demand (e.g., feeling hungry), or an indirect or implied demand (e.g., being handed a homework assignment).
Pathological demand avoidance, ADHD, and autism spectrum disorder
While pathological demand avoidance was originally linked only to autism spectrum disorder, many experts believe it is also a profile of ADHD. In one study, researchers found that ADHD behaviors were more predictive of PDA than ASD behaviors. ADHD is associated with impulsivity, impaired executive functioning, and difficulty with emotional regulation—all of which can contribute to defiant behavior. Further, the high level of comorbidity between ADHD and ASD may explain the existence of a PDA profile of ADHD.
Understanding comorbid ADHD and autism spectrum disorder
Research suggests that 50% to 70% of individuals with ASD also live with ADHD. Some experts believe that pathological demand avoidance occurs in people with ADHD primarily when there is a comorbid autism diagnosis. The symptoms of ADHD and autism spectrum disorder overlap in many ways. Both ADHD and ASD are marked by emotional dysregulation, which can lead to mood swings and severe distress. Additionally, both disorders can lead to executive dysfunction, making it hard for children to engage in goal-directed behavior. Both of these sets of symptoms can contribute to difficulties with demand avoidance.
ADHD and ASD also differ in key ways. For example, ADHD typically involves less rigidity and fewer repetitive behaviors than autism spectrum disorder. Still, inflexibility can occur in individuals with ADHD. Many people with ADHD engage in hyper fixation, focusing on one activity or subject for extended periods. Additionally, children with ADHD often struggle switching tasks, which can cause them to experience discomfort when they are told to stop what they’re doing. These tendencies can contribute to inflexibility and trouble with demands.
Treating demand avoidance
The traditional forms of treatment for ADHD may be tweaked to address a child’s PDA profile and potential symptoms of autism spectrum disorder. Commonly, ADHD is treated through medication and therapy. A child living with demand avoidance ADHD may benefit from psychotherapy that alleviates emotional distress caused by anxiety. Additionally, ethical forms of social skills training and related interventions may help them communicate effectively and foster healthy interactions.
Medication may be prescribed in some cases, though its use can depend on whether the ADHD or ASD symptoms are more severe. There is evidence that the non-stimulant guanfacine can alleviate symptoms of comorbid ADHD and ASD, specifically oppositional behavior. Consult a healthcare professional before starting or stopping any medication.
The BetterHelp platform is not intended to provide information on which medication or medical treatment may be suitable for you. The content provides generalized information that is not specific to one individual. Do not take any action without consulting a qualified medical professional.
Managing anxiety and promoting flexibility: How to support a child with PDA
Defiant behavior caused by PDA is caused by serious emotional distress, and not laziness or hostility. If you have a child with marked demand avoidance and ADHD, helping them manage their anxiety, remain flexible, and develop important skills can contribute to their ability to live a healthy, productive life. The following are strategies for supporting a child with PDA.
Managing anxiety
Because PDA is marked by heightened nervousness and worry, approaching demands in a calm and measured way can help you avoid extreme emotional responses. Avoid raising your voice or making rushed movements, as these can convey a sense of urgency. Anxiety may not be visible. When they’re nervous, your child may withdraw into their room or shut down, rather than expressing their emotions outwardly.
As you work to alleviate your child’s anxiety, try to develop a better understanding of the situations that lead to elevated distress in your child. Do they experience severe anxiety due to difficulty staying organized? Are emotional responses more powerful when time constraints are imposed? Understanding the perceived demands that exacerbate anxiety may help you mitigate their impact.
Promoting flexibility
Extreme demand avoidance can occur when children exhibit inflexible behavioral patterns. Parents may address this rigidity by helping their child understand the benefits of flexibility. Demonstrating to your child that they will have more options in the future by being flexible may help them feel better about responding to demands constructively.
Flexibility can also be important for caregivers, who may struggle when children cross boundaries with PDA. Try to maintain an adaptable approach to enforcing rules, potentially providing your child with leeway when their emotional responses are heightened. According to the PDA Society, maintaining a malleable schedule can also be important. Children with ADHD often experience time blindness. Additionally, time limitations can be perceived as additional demands by children with PDA. Allocating extra time to tasks can help you avoid exacerbating the emotional challenges of demand avoidance.
Using non-demanding language
Your child may be more likely to perceive certain statements as demands. For example, words such as “must,” “need,” and “immediately” can convey a sense of urgency that may feel overwhelming to your child. Instead, try to use indirect language and requests that offer a choice. For example, you might say, “Perhaps we can clean up these toys today,” or “What if we try to do homework at four instead of five today?”
Providing structure
While flexibility can be key, it is also essential to establish certain rules that should not be broken. Thoroughly explain these boundaries and clearly delineate acceptable behaviors. Initially, these rules may be basic. Over time, however, you may be able to impose increasingly restrictive boundaries while maintaining an overall flexible approach.
Seeking support as a caregiver
For parents and other caregivers of children with ADHD and PDA, a mental health professional can be a source of emotional support, helpful insights, and useful guidance. A therapist can help you understand the causes of your child’s behavior and develop strategies for addressing it.
A professional can also help you address mental health concerns you may be experiencing. Research suggests that caregivers of children with ADHD are at higher risk of depression and anxiety. By addressing parenting challenges and promoting emotional wellness, you can ensure that you are prepared to provide your child with the best possible care.
How online therapy can help
If you’re seeking help as a caregiver of a child with ADHD, consider getting matched with a mental health professional online. Online therapy is a convenient and cost-effective way for busy parents to receive guidance and support.
Exploring demand avoidance ADHD in online therapy
With an online therapy platform like BetterHelp, scheduling is flexible, allowing you to attend sessions at times that work for you. Online therapy is also an affordable option—BetterHelp memberships start at $70 per week, billed every four weeks.
Research suggests that online therapy can help parents address behaviors related to demand avoidance and ADHD. For example, in one study, researchers found that an online parent training program was as effective as a face-to-face intervention when addressing behavioral challenges in children at risk of ADHD. The study found that online therapy resulted in significantly improved mood, self-control, and impulsivity.
Takeaway
Is demand avoidance ADHD or autism?
Demand avoidance was initially studied concerning the typical symptoms of autism spectrum disorder. In child psychology and adolescent health research, most of the understanding of pathological demand avoidance concerning neurodevelopmental disorders was done on autism. However, some experts in communication disorders and adolescent psychiatry are starting to believe this symptom is also common in ADHD. More research is recommended to understand the connection. PDA is not listed in the ADHD or ASD diagnostic criteria in the DSM-5, so neither condition requires this symptom for diagnosis.
When does demand avoidance become pathological?
Demand avoidance is pathological when it impedes someone’s ability in daily life. For example, if a child struggles to clean and never cleans because they avoid demands, the mess can lead to an unhealthy lifestyle and potentially be harmful. It is important for children to learn skills like organization and cleaning, even if they seem like unnecessary rules.
How do you help demand avoidance in a kid with ADHD?
You may be able to reduce demand avoidance in children with ADHD by including them in decisions, respecting their autonomy, and not phrasing demands as demands but as requests, even if the child must do it. Recognizing triggers may also be helpful and reduce the risk of intense mood swings and obsessive behavior. Children may be more likely to have panic attacks if they experience a significant amount of pressure. Letting your child know they can complete it within their own time or setting up a more flexible timeline to complete tasks may be helpful, especially if you offer a reward system.
Do ADHD meds help with demand avoidance?
ADHD medications may reduce demand avoidance if it is caused by hyperactivity or hyper-attention. However, demand avoidance is often a side effect of time management difficulties, a lack of organization, and difficulty accepting authority. Children with social and communication disorders like ADHD and autism may have a high sense of justice, which can lead to them not wanting to follow rules if they don’t understand them or don’t believe they’re necessary. For this reason, treating your child as somewhat of an equal and as a human being may help them see you less as an authority figure and more as someone trying to work with them instead of against them.
What does demand avoidance feel like?
Demand avoidance can be like a sensation of distress, annoyance, or anger. For some, demands cause extreme anxiety that can be similar to ADHD symptoms or anxiety disorder symptoms. Evidence suggests PDA-related symptoms are most common in people with autism, which is a pervasive developmental disorder, though people with ADHD can also experience them. By working through demand avoidance, whether you or a loved one has these conditions, you can develop more fulfilling lives and make positive changes. The ADHD and autism community are continuously working to recommend further studies on how symptoms impact these groups.
What are the symptoms of pathological demand avoidance in children?
The symptoms of PDA in children tend to include irritability, anxiety, anger, or defiance when demands are placed on them. Adults can also experience these symptoms, though children may have more difficulty regulating their emotions. They might act out in rage or do the opposite of what is asked of them. For example, if the child is in their room and has decided they will clean later in the day, and their parent comes in and asks them to clean, they will decide not to clean at all, even though they previously wanted to.
What age does PDA show up?
PDA can show up at any age, though it might be more common in elementary and middle school students, who are starting to gain independence in certain ways. Teens can also struggle with PDA, though their defiance can look different. For example, they might act out more by using substances, leaving home, or completely disregarding their parents or teachers. Adults with PDA may struggle to hold a job where they don’t have authority, especially when they don’t agree with management or the way the company runs the business.
How do you treat demand avoidance ADHD?
Demand avoidance is often treated using different parenting methods, therapy, and, in severe cases, medication. Parents can play a significant role in helping their children with this symptom, as it often arises from the way the brains of children with developmental disabilities work.
How do you overcome avoidance with ADHD?
If you have avoidance with ADHD, you might overcome this habit by changing how you ask yourself to complete tasks or interact with authority. You might also benefit from trying to find a career that allows you some control over your schedule, time, and duties, so you don’t get frustrated and burned out from listening to someone tell you what to do. You can also give yourself more patience and kindness in your thoughts. If you’re struggling to complete a chore, tell yourself in your mind, “It’s okay, you’re stressed right now. You’ll do this when you’re ready.” Giving yourself the choice of when you complete the task instead of telling yourself, “I must do it right now or I’m a bad person,” can be much more effective.
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