An Introduction to Pathological Demand Avoidance (PDA)
Pathological Demand Avoidance of PDA is becoming more widely recognized as a distinct profile of autism. British psychologist Elizabeth Newson came up with this term which describes an anxiety-driven need to be in control and avoid other people’s demands and expectations. Research done at the University of Newcastle in November 2016 found that Intolerance of Uncertainty (IU) was also associated with PDA, in fact even stronger than anxiety.
Demand avoidance in the PDA profile looks different from what others on the autism spectrum experience because of its extreme nature and obsessive quality. This extreme avoidance extends to the most basic demands of everyday living, not just the avoidance of unpleasant, difficult, specific anxiety-provoking or unappealing tasks. Someone with a PDA profile will also have tremendous difficulty complying with their own self-imposed expectations and with doing things that they really want to do. (PDA Society, UK)
PDA is seen in both genders equally. There are no prevalence rates available at this time. It is not caused by a how a person was raised or their social circumstances; it’s not the fault of the parents or the individual with the condition.
PDA is not recognized in the DSM-V so not all professionals agree with this profile. We have not heard much about PDA in North America yet, although the term is starting to become more known. The interest in PDA as a distinct profile is growing and more research is being done. Because PDA is a fairly recent profile, it’s often misdiagnosed as other conditions that look similar on the surface such as Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), Reactive Attachment Disorder (RAD) and Attention Deficit Hyperactive Disorder (ADHD).
Features of Pathological Demand Avoidance (from the PDA Society, UK)
1)Resisting and avoiding the ordinary demands of life
This might include getting up, joining a family activity or getting dressed to name but a few. This may be the case even when the person wants to do what has been suggested, such as watching a film that they have been looking forward to. When initial avoidance strategies, such as those described below fail; the situation can quickly escalate and some individuals may resort to more extreme measures to avoid the demand such as shouting, swearing, hitting and damaging property. Others may, shut down, withdraw or run away. This is a meltdown and should be viewed as a panic attack.
2)Using social strategies as part of the avoidance
Distracting – “I like your earrings, where did you get them from”, giving excuses – “I can’t walk because my legs are broken”, delaying – “I’ll do it in ten minutes”, withdrawing into fantasy – “I’m a cat and cat’s don’t wear clothes” and drowning out your request with noise “I can’t hear you because I’m singing – la, de, la, de, la …..”.
3)Appearing sociable on the surface
People with PDA may have a more socially acceptable use of eye contact. Their conversational skills may appear better than others on the autism spectrum, but this is still often lacking depth in their understanding. For instance, not seeing a difference between themselves and an authority figure, having difficulty in adjusting their own behaviour in response to the needs of others and not always understanding how, or why their behaviour can affect others at an emotional level and thus have a negative impact on their relationships.
4)Excessive mood swings and impulsivity
e.g. They can have great difficulty in regulating their own emotions and controlling their reactions to situations and people. The individual can rapidly switch from happy and engaging – to angry or sad in seconds, often with no visible build up or warning to others. This may be in response to pressure of demands and perceived expectations.
5)Being comfortable in role play and pretense, sometimes to an extreme extent and the lines between reality and pretense can become blurred
e.g. Often adopting the persona of a figure of authority in role play scenarios to such an extent that they believe that they are that person. This role may often require them to oversee and direct others and as such, remain in control of the play e.g. taking on the role of a teacher when playing with peers. Role play can be used as a strategy to avoid demands made by others such as “I can’t pick that up because I’m a tractor and tractors don’t have hands” or role playing the compliant child in school to reduce demands by flying under the radar. Withdrawing into fantasy can also be a form of self-protection, a place where they can go to when real life becomes too difficult to manage and to cope with.
6)‘Obsessive’ behaviour that is often social in nature
People with PDA may often become obsessive about other people, either real or fictional, from either a love or hate perspective, which can make relationships very tricky. Newson et al, noted that the demand avoidant behaviour itself also has an obsessive quality.
What does extreme demand avoidance look like in PDA?
Triggers – demands or situations that will cause anxiety such as social situations or a change in routine but this will also extend to all everyday demands, expectations and suggestions, including activities that the individual would usually enjoy or want to do.
How someone with a PDA profile avoids a demand – usually uses social strategies to begin with such as making excuses, using distraction, incapacitating themselves, drowning out the request with constant interruptions or adopting the persona of another person or character. If these strategies don’t work, more extreme strategies can be used such as shouting, swearing, aggression or fleeing.
Strategies to Support – provide a flexible and adaptable approach that is constantly in sync with the person’s anxiety levels. The Low Arousal Approach encompasses these ideas for recognizing when arousal mechanisms are becoming engaged, when and how to reduce demands, and how to support a person who is highly anxious or stressed. Reasons for demand avoidance such as sensory overload, emotional overload, communication difficulties, fear of uncertainty can be addressed using autism strategies but they must be adapted so that they are delivered in a non-direct manner. Again, low arousal approaches will help here.
Most of the information for this post was taken from the PDA Society website in the UK. It is the most comprehensive website on this topic so please visit their page for more information. If you think your child may have PDA, the Society has a section with a questionnaire and webinar. There are also supports for teachers, professionals, adults with PDA, and families along with an extensive resource section.
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