Conditions

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 […]

therapist sean abraham By Sean Abraham, LCSW

Updated on Jan 12, 2024

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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.

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. 

Demand avoidance often occurs when something is new or uncertain in the day.

- Rainier Wells, LMHC

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:

Symptoms of PDA

Symptoms of PDA in individuals can include:

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:

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:

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:

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. 

What Is the Treatment for PDA?

There’s no cure for PDA. PDA 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.

PDA is not a disease or disorder but a personality profile.



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:

Parents of children with PDA could:

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:

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.

Takeaways

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.

FAQs

  • It’s possible to have both PDA and ADHD at the same time, according to research. People with ADHD who don’t have PDA may struggle to follow instructions and demands. However, this may be because they have trouble concentrating, managing their impulses, sitting still, or managing their time — not because instructions trigger them. On the other hand, people with PDA who don’t have ADHD may not have symptoms like a lack of focus, hyperactivity, or impulsivity.

  • There isn’t a difference between PDA and EDA: they refer to the same personality profile and characteristics. But many people prefer the term EDA. The word “pathological” can have a negative connotation. Because of this, some clinicians and advocates use the term extreme demand avoidance (EDA) as an alternative term for PDA. Another popular term proposed to replace pathological demand avoidance is “Pervasive Drive for Autonomy,” which emphasizes that the person has an anxiety-driven need for self-determination. The term was developed by Tomlin Wilding, a neurodivergent activist.

  • There are many online resources for people with PDA: - National Autistic Society – Pathological Demand Avoidance and PDA Society has a range of resources for people with PDA and their loved ones. - PDA Society also has a list of local support groups. - PDA Parents can help the parents of children with PDA and parents who have PDA themselves. They also have a podcast on PDA. - Check out Harry Thompson, Kristy Forbes, and Sally Cat for personal perspectives on PDA. - Online forums and support groups may also be helpful.

About the author
therapist sean abraham Sean Abraham, LCSW

Sean Abraham is a licensed clinical social worker who works with those who have struggled with substance use, depression, anxiety, loss, communication problems, student life, as well as other mental health concerns.

This article is not meant to be a replacement for medical advice. We recommend speaking with a therapist for personalized information about your mental health. If you don’t currently have a therapist, we can connect you with one who can offer support and address any questions or concerns. If you or your child is experiencing a medical emergency, is considering harming themselves or others, or is otherwise in imminent danger, you should dial 9-1-1 and/or go to the nearest emergency room.

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