Navigating pathological demand avoidance (PDA) in autism and ADHD

Have you ever found yourself avoiding a task because someone told you to do it? Perhaps you’ve avoided the dishes after your partner asked you to do them. Or maybe your boss showed you how to do a project, and you found yourself deliberately doing it differently.

If you’ve ever experienced this, you’ve seen what it’s like to live with pathological demand avoidance (PDA). PDA is a behavioral profile associated with autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD).

For people with PDA, following instructions can be difficult even if they want to comply. People with PDA might even struggle to follow routines and plans they set for themselves. Put simply, you can view demand avoidance as “a resistance to the demands of life,” says Grow Therapy provider Rainier Wells, LMHC.

To outsiders, people with PDA might seem stubborn or rebellious. But PDA isn’t a choice; it’s a severe struggle for people with PDA to comply with demands even when they want to. Living with PDA can be frustrating, but managing your symptoms healthily is possible. Read on to learn how to cope with PDA.

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What is pathological demand avoidance?

Pathological demand avoidance (PDA) — sometimes also called extreme demand avoidance (EDA) — is a proposed subtype of autism. It affects both adults and children.

People who fit into the PDA profile struggle to comply with demands. “These types of demands include the demands of internal body cues or thoughts, stated demands or requests by others, and implied expectations of life communicated by body language, verbal intonation, or assumptions,” says Wells.

These demands can include instructions, suggestions, or requests. Even following their routines and plans may take time and effort.

For people with PDA, ordinary demands might give them extreme anxiety levels, possibly leading to meltdowns or panic attacks. They may go to great lengths to avoid complying with demands.

“It is common for those with demand avoidance to immediately decline or avoid any demand due to needing more processing time and trying to understand or acclimate to this new request in their day,” Wells says. “Demand avoidance often occurs when something is new or uncertain in the day.”

Origins of PDA

Child psychologist Elizabeth Newson coined the term “pathological demand avoidance” in 1980. She developed the term based on her observations of children diagnosed with pervasive developmental disorders (PDD), now known as autism spectrum disorder.

Understanding PDA

Many people consider PDA to be a subtype or profile of autism, according to the PDA Society. PDA is also associated with ADHD. However, there’s no official consensus on whether PDA is a disorder.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Statistical Classification of Diseases and Related Health Problems (ICD-10) — which clinicians use the DSM-5 and ICD-10 to classify and diagnose health conditions — do not recognize PDA as a condition. This is also different from a diagnosis prevalent in children, Oppositional Defiant Disorder, which involves similar behaviors without a diagnosis of Autism Spectrum Disorder.

What are the signs of PDA in autism?

All people show resistance to demands on occasion. Most people dislike being bossed around, and everybody can occasionally be stubborn. The difference between PDA and ordinary stubbornness is that PDA is more intense and pervasive.

Characteristics of PDA

According to the National Autistic Society, people with PDA have the following core characteristics:

• Resist and avoid everyday demands: They may go out of their way to avoid complying with instructions, suggestions, and requests. Ordinary demands may be highly distressing to them.

• Use social strategies to avoid demands: For instance, they might become manipulative, lie, or blame others.

• Are sociable on a superficial level: Autistic people with PDA might be more sociable than most people with ASD. However, they might lack a deeper understanding of social situations.

• Experience mood swings and impulsivity: They may have rapid and extreme mood swings.

• Comfort in role-play and pretend: Compared to other people on the spectrum, children with PDA feel more comfortable engaging in role-play and pretend. They may use this as a way to avoid demands.

• Exhibit obsessive behavior: People with PDA often become obsessively attached to other people.

Did you know?

Research suggest that around 40% of autistic individuals have a co-occurring anxiert disorder. For people with a PDA profile, anxiety is considered the core driver of demand avoidance.

Symptoms of PDA

Symptoms of PDA in individuals can include:

• Anxiety: Most people with PDA experience high levels of anxiety, especially when faced with a demand or expectation.

• Controlling behavior: People with PDA might have a deep-seated need for control. They might feel anxious when they’re not in control.

• Social difficulties: Although they may have better social skills and communication skills than most people on the spectrum, people with PDA may experience social difficulties because of their demand avoidance.

• Sensory processing issues: Like many people with autism, they might have unusual sensory experiences, making them bored or overstimulated easily.

• Being unresponsive to conventional approaches: According to the PDA Society, conventional parenting, teaching, and support approaches often don’t work for people with PDA.

Not everyone with PDA will check all the above boxes, and every person with PDA has a different experience.

Outcomes of PDA characteristics and symptoms

Because people with PDA will avoid demands and suggestions, they might experience strained relationships with peers and authority figures (including parents, teachers, and employers). However, people with PDA can manage their symptoms to have healthy relationships.

What are the triggers for PDA?

Demands trigger people with PDA to become avoidant. But what exactly are “demands?” Demands can be instructions from others and general implications, suggestions, and expectations. They can be:

• External demands, which are imposed by others (parents, teachers, boss, partner)

• Internal demands, which are imposed by yourself (like a routine, plan, or schedule you’ve set for yourself)

• Explicit demands, like an instruction or rule

• Implicit demands, like a suggestion, unsaid expectation, or request for help

When we think of demands, we may picture a teacher standing over us, telling us to complete a task. Or a parent commanding us to put on our shoes immediately. But demands can also look like:

• Your partner suggesting you put a coat on

• A housemate politely requesting that you sweep the kitchen floor

• A routine you planned out for yourself

• The unsaid expectation that you’re quiet in a library or place of worship

Every person with PDA is different. Some might find internal demands easier to adhere to than external demands. Likewise, it may be easier for some people to comply with suggestions than explicit instructions.

How is PDA in autism diagnosed?

PDA isn’t recognized as a distinct disorder or condition. Because of this, there aren’t any universal diagnostic criteria for PDA. One tool for identifying the traits of PDA is the ‘Extreme Demand Avoidance Questionnaire’ (EDA-Q), developed in 2013.

There are, however, specific diagnostic criteria for an autism spectrum disorder (ASD) diagnosis. If you think you or your child is autistic, book an appointment with a therapist or psychiatrist specializing in autism.

Mental health professionals specializing in ASD or ADHD might be able to identify PDA and provide PDA-specific support.

What is PDA misdiagnosed as?

Because PDA is not universally acknowledged as a subtype of autism or a disorder in itself, it’s poorly understood. Even clinicians might not recognize the symptoms of PDA.

This might lead to a misdiagnosis (where someone with PDA is diagnosed with a disorder they don’t have) or a missed diagnosis (where a clinician doesn’t diagnose them with PDA at all). PDA may be misdiagnosed as:

• Oppositional defiant disorder (ODD): Both PDA and ODD can involve an ongoing pattern of defiance of authority, irritability, and anger.

• Disruptive mood dysregulation disorder (DMDD): Children with DMDD may seem irritable, noncompliant, and angry towards authorities.

• Mood disorders (like depression or bipolar disorder): Mood disorders can cause irritability and make it harder to carry out tasks. During a manic period, people with bipolar disorder may act recklessly and seem noncompliant.

• Anxiety disorders (like generalized anxiety disorder): Many people with PDA experience heightened anxiety levels when faced with demands.

Having PDA and another mental health condition or neurodevelopmental disorder is possible.

As mentioned, PDA is associated with both autism and ADHD. Someone with either condition might have their PDA symptoms attributed entirely to that condition — in other words, a mental health professional might put their symptoms down to ADHD or autism without recognizing that they fit the PDA profile.

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What is the treatment for PDA?

There’s no cure for PDA. It is not a disease or disorder but a personality profile.

However, living with PDA can be frustrating because the symptoms can affect your day-to-day life. Coping with demand avoidance can be difficult, especially when you struggle to follow demands you want to comply with.

“Individuals with demand avoidance can improve their lives through sensory regulation, increasing interoception — internal cues — through mindfulness and routine, scheduling extra time before and after activities, assertiveness training to set boundaries and communicate needs, and reducing unnecessary additions to communication,” says Wells. “These techniques can be learned through therapy with a neurodivergent or neurodivergent-friendly therapist, peer support, and bibliotherapy.”

A great way to assist with PDA is to work on changing one’s language in small, but significant ways. The more someone says they “should,” “shouldn’t,” “have to,” or “need to” do something, the less likely they are to do that task as it feels like a chore. If the language changes to “want to,” “would like to,” “could,” “can,” or “will,” there is less judgment and more motivation involved.

A number of other strategies may also help you cope with daily life while living with PDA. For example:

• Learn more about PDA

• Learn to recognize your triggers

• Manage your anxiety levels, which can be a big part of your PDA

• Avoid sensory overload if you’re prone to overstimulation

• Embrace neurodiversity: Your brain is not “broken,” it’s just different — all people are different, which is a good thing!

• Embrace your positive qualities

Parents of children with PDA could:

• Learn about PDA and how to recognize their child’s triggers

• Disguise demands as games and suggestions

• Minimize unnecessary rules

• Explain the importance of essential rules

• Give your children some control and freedom

• Don’t take their behavior personally

• Help them manage their anxiety

Can therapy help with PDA?

Therapy can help people with PDA. Counseling provides a space to process your feelings, learn more about PDA, and reflect on techniques and strategies that work for you. Counseling could assist with:

• Helping you understand PDA

• Learning skills to manage your symptoms

• Gaining perspective on relationships

• Managing any other conditions you might have

In addition to talk therapy, occupational therapy can be helpful for people with PDA. However, the PDA Society points out that therapy can feel like a demand in itself, which can be difficult to navigate. It’s a good idea to choose a therapist who’s experienced in treating people with PDA.

Every person with PDA is different. What might work well for one person may not work for the next. Experimenting with different strategies to see what will work best for you may be a good idea.

What is the outlook for PDA autism?

While PDA can’t be “cured,” many people with PDA live happy and successful lives.

The PDA Society shares stories and experiences from real people with PDA (or, as they often call themselves, “PDAers”). Many of them have gone on to lead fulfilling lives filled with meaningful experiences and relationships.

It is possible to manage the symptoms of PDA, cope with demand-related anxiety, and find supportive resources.

Depending on your situation, you might find it helpful to connect with a therapist who treats autistic people. Support groups and online resources may also help you find a sense of community and learn more about PDA.

Final thoughts

People with PDA find it hard to follow demands — ordinary demands can make them incredibly anxious. As such, they might go to extreme lengths to avoid complying with instructions and suggestions.

Someone with PDA might seem antagonistic, stubborn, or delinquent to outsiders. But their behavior is not their fault.

While it can be frustrating to live with PDA, it’s possible to manage the symptoms healthily and effectively. Living a happy and fulfilling life with PDA is possible with the proper support. Find a therapist at Grow Therapy today and get the support you need.

Living with PDA is manageable — you don’t have to figure it out alone.Find a specialist