Pathological Demand Avoidance (PDA) And Autism Spectrum Disorder
Most children resist demands from their parents from time to time because they don’t understand or agree with a given command. However, when a young person experiences a compulsion to oppose requests or commands, they may be living with pathological demand avoidance. Pathological demand avoidance, often shortened to PDA, is a set of symptoms that many children with autism spectrum disorder and other developmental disorders experience. While PDA can be challenging for both children with autism and their parents or caregivers, it can also often be managed with the right support. Below, we’re providing an overview of pathological demand avoidance, outlining approaches for addressing its symptoms, and discussing options for parents of children with PDA to seek mental health support.
An overview of pathological demand avoidance (PDA)
Pathological demand avoidance (PDA) involves extreme attempts to resist complying with commands or requests. PDA is not itself a disorder. Instead, it is a profile: a set of symptoms that can be attached to certain behaviors or developmental disorders.
When first recognized by psychologist Elizabeth Newson in 1983, PDA was conceptualized as a pervasive developmental disorder—a group of conditions that then included autism. Today, because autism is viewed as a spectrum, PDA can be thought of as a profile of autism spectrum disorder (ASD). It is estimated that up to 20% of children with ASD experience PDA. In addition to ASD, PDA is associated with attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder.
Often mediated by anxiety, pathological demand avoidance can seriously impact a young person’s emotional well-being and ability to function. PDA can also create significant complications for caregivers. In recent years, however, a better understanding of the PDA profile has provided professionals and caregivers with insights into how to manage its symptoms.
Symptoms of pathological demand avoidance (PDA)
Children who experience pathological demand avoidance may exhibit extreme reactions when asked or told to do something. Demand avoidance behaviors may be in response to a direct request (e.g., asking them to clean up their space), an internal command (e.g., attempting to get oneself out of bed), or an indirect or implied demand (e.g., hearing a school bell). A child with the PDA profile of autism spectrum disorder may have a meltdown or panic attack when given a demand. They may begin breathing rapidly, sweating, or feeling dizzy. Their demeanor may change rapidly, from pleasant and calm to irritable and angry.
The following are the primary symptoms of pathological demand avoidance:
- Strong emotional responses to everyday demands
- Extreme methods of avoidance, such as threats and diversions
- Drastic fluctuations in mood
- Impulsive behavior
- Obsessions with people
If you believe your child may be living with pathological demand avoidance, consider consulting with a child or adolescent mental health specialist. A healthcare professional can provide screenings and determine whether further testing, a diagnosis, and treatment may be necessary.
Causes of demand avoidance: Anxiety and other contributors to PDA
Additionally, executive dysfunction—difficulty engaging in goal-directed behavior—may contribute to marked demand avoidance in children with autism. Because of executive dysfunction, it may be hard for a young person experiencing demand avoidance to understand the reasoning behind ordinary demands. As a result, when authority figures ask them to do something, they can become overwhelmed and upset.
Treatment for demand avoidance associated with autism
Like many forms of care for children with an autism diagnosis, pathological demand avoidance is usually treated through various psychosocial interventions. These may include parent training, skills training, psychotherapy, and related approaches.
Parent training is a way for caregivers to better understand ASD and PDA, develop helpful coping strategies, and strengthen their bond with their child. Parents can learn how to create structure, help with the development of social skills and emotional regulation, and promote flexibility in their child’s life.
Skills training can also help children with PDA learn how to communicate effectively and improve their executive functioning. When children feel better able to exert their autonomy, they may experience less fear and nervousness when confronted with demands.
Often, psychotherapy focuses on helping children with PDA regulate their emotions so that their responses to demands are constructive and healthy. A commonly utilized form of psychotherapy for the PDA profile is cognitive behavioral therapy, which is centered around the connections between a child’s thoughts, feelings, and actions. With CBT, a therapist can help a child reframe negative thought patterns that may be underlying strong emotional responses to demands.
Providing support to children with demand avoidance
Children with PDA related to autism often do not respond as well to traditional behavioral approaches, which tend to focus on rewards or praise. Instead, it can be important for parents to remain flexible and calm while creating a structured environment for their child. The following are strategies that may help you support a child with PDA, in addition to seeking professional support as needed.
Learning more about PDA and autism
Education is often a primary component of parent training for autism spectrum disorder. Learning more about the causes of demand avoidance and how it can manifest may help you provide the care your child needs.
Developing flexibility
Because children with PDA are often rigid in their behaviors, helping them see the value in flexibility can be crucial. You might try to show your child that they will ultimately benefit from being flexible.
Additionally, it can be important for you to be flexible too. Often, achieving the desired behavioral response involves negotiating or changing your approach. For example, you may want to alter the phrasing of a demand if your child is becoming overwhelmed. It can also be important to know that your child’s fulfillment of your request may not look exactly like you expected, despite the fact that they attempted to meet your expectations.
Alleviating anxiety
Children with PDA typically avoid demands due to their fight-or-flight response kicking in. This reaction can cause feelings of overwhelm, physical tension, and nervousness. To alleviate these emotional responses, you might try to stay calm when you’re making requests or commands. It can also be important to remember that a child with PDA’s defiance is not personal—it is typically a result of serious emotional distress that they are attempting to avoid.
Creating structure
While flexibility is crucial, it can also be important that you set certain boundaries. Establishing basic rules can help your child become accustomed to behaving within certain limits.
Part of creating structure is helping your child with time management. When developing a schedule, consider allocating more time than you think you need. According to the PDA Society, when creating a schedule, it can help to “plan ahead, anticipate potential challenges and allow some flexibility to accommodate fluctuating anxiety levels.”
Communicating effectively
The way you frame a request or demand can influence your child’s response. Phrasing that emphasizes a sense of urgency or seriousness may be met with negative reactions. For example, words like “immediately” or “have to” may exacerbate feelings of overwhelm. Instead, you might try to formulate demands so that they feel like choices (e.g., “What if we start getting ready for bed?”).
Seeking mental health support as a caregiver
Parents and other caregivers of children with PDA can experience serious mental health concerns, including stress and anxiety. If you’d like mental health support as you navigate parenting challenges, therapy may be helpful. In addition to providing you with emotional support, a therapist may be able to give you advice on helping a child with ASD and PDA.
How online therapy can help
If you’re a busy parent who wants to participate in therapy without the commute, you might consider working with an online therapist. Online therapy can be a more convenient and affordable method of mental health care for parents seeking to provide children with PDA the support they need.
Addressing demand avoidance, autism, and other parenting concerns in online therapy
With an online therapy platform like BetterHelp, you can address parenting challenges related to PDA or other concerns with a licensed therapist remotely, through video call, voice call, or in-app messaging. Online therapy is also typically more affordable than in-person therapy without insurance.
The effectiveness of online therapy
Research suggests that online therapy can often be as effective as traditional, in-person approaches. For example, researchers in one study reported that participants experienced “sustained and clinically meaningful improvements” in symptoms of depression and anxiety after undergoing an online talk therapy treatment.
Takeaway
What are avoidant behaviors in autism?
Avoidant behaviors in autism in everyday life can come from pathological demand avoidance that arises when direct demands are placed on a child or person by education professionals, parents, and other authority figures. Children with autism who face internal demands or implied expectations from others may become overwhelmed quickly, which can lead to heightened anxiety, frequent stimming, intense emotional distress, panic attacks, and PDA behaviors, such as eloping (running away) or refusing to complete a task. Appropriate support from a professional can help improve child health and reduce avoidance behaviours.
Do kids grow out of pathological demand avoidance?
Children can learn skills that help them cope with pathological demand avoidance, though the emotions may still come up in daily life. Parents can help their child by reducing the number of expectations they set and reframing how they tell their child to do a task. For example, roleplay, fun activities, reward motivation, and rephrasing demands as a request may be helpful. Children with developmental disabilities can have difficulties with understanding why they feel the way they do, so it can sometimes be up to parents to discern why a child is having a meltdown or struggling. Instead of calling them “disobedient” or “defiant,” try to look at the root of the issue and accommodate your child for the way their unique mind works. Accommodating support strategies can be a key factor in the success of the treatment of PDA (pathological demand avoidance) and associated symptoms, according to organizations like the National Autistic Society and Autistic Self-Advocacy Network.
What causes demand avoidance?
Demand avoidance may be caused by the typical symptoms of autism spectrum disorder and other developmental conditions, such as ADHD. Persistent and marked resistance to demands and authority can be due to the strong sense of justice in those with these conditions, as well as the desire to understand “why” one is being asked to complete a task. If an autistic child doesn’t find a task necessary or understandable, such as being asked to complete a social norm that isn’t necessary to them, they might not want to.
In addition, the hyperfocus common in those with autism can lead to them not wanting to turn away from anything that gives them pleasure and joy. For example, if they are working on a project regarding their special interest and their teacher asks them to clean up the trash in the classroom, they might become highly distressed, mainly because there is no time to transition between something they enjoy and something that causes distress or labor. In this case, they might have a meltdown, refuse, or run out of the classroom. If the situation is escalated, such as by the child being restrained or yelled at, they may have a worse meltdown, which can cause trauma and further resistance in the future.
What is one of the three signs of an autism spectrum disorder?
One of the biggest signs that a child has autism spectrum disorder is delayed developmental milestones. For example, they might walk, talk, or socialize later than other children. They might not interact with their environment as much and may not make eye contact when talking to others. Talk to an expert in child and adolescent psychiatry, such as a psychiatrist or therapist, to learn more about getting your child diagnosed.
What age does PDA start?
PDA can start at any age, but it becomes most noticeable when a child is old enough to respond to commands. For example, elementary-aged children may be more likely to have PDA behaviors. Teens and middle school children can also struggle with PDA.
How do you help a child with demand avoidance?
If your child struggles with demand avoidance, you may help them by removing pressure to act a certain way. Instead, you can check in with them about their unique needs and desires and find ways to compromise. Try to avoid labeling them as “lazy,” “defiant,” or “rude.” Instead, tell them you understand that being asked to complete certain tasks can be stressful and that you want to work with them instead of against them. You may also consider getting them support through therapy or psychiatry.
What does PDA look like at school?
A child might show symptoms of PDA at school by refusing to do schoolwork, becoming highly emotionally distressed by teacher requests, and speaking back to authority figures. Children may have more difficulty with certain types of authority figures, such as those who adamantly push their requests with no empathy and struggle to understand why the child is distressed. Parents may make a positive difference for both educators and their child by working with the school around their child’s unique needs and considering accommodations.
How do I know if my child has pathological demand avoidance?
Your child might have pathological demand avoidance if they frequently become highly upset about requests from authority figures and struggle to cope with deadlines, projects, and time management. Although not a mental illness in itself, PDA is common in certain developmental disorders, such as autism spectrum disorder and ADHD. Talk to your child’s pediatrician or therapist if you notice these challenges in them.
What is the therapy for demand avoidance?
Many therapeutic modalities can be used to remedy demand avoidance in people of any age. Cognitive-behavioral therapy (CBT) may be a helpful modality, supporting children in understanding the beliefs and emotions behind their avoidance. When children better know what’s occurring, they may be better able to advocate for themselves and know when to take a break before they become overwhelmed.
How do you discipline a child with PDA?
If your child has PDA, they might react poorly to authoritarian or typical discipline methods parents use, such as raising your voice, telling them to go to “time out,” or taking away their items. Instead, you might consider offering consequences that make logical sense alongside the reason they’re being disciplined. For example, if they didn’t do their homework, the logical consequence might be having them lose their video game privileges until the homework is done. If they made a mess, the result is cleaning up the mess. After they clean it up, they can go back to playing and having fun. Finally, if they were rude to someone, their consequence may be writing an apology letter to that person. Instead of taking their joyful activities away in response to every mistake, make the consequences fit the severity and theme of the mistake they made.
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