What is Pathological Demand Avoidance?
Pathological Demand Avoidance (PDA) is a neurodevelopment condition that is often considered to be a profile within the autism spectrum. PDA is characterised by overriding, non-rational avoidance of everyday demands and expectations, even those the individual may want to carry out.
PDA people still experience rational demand avoidance alongside the non-rational kind.
Importantly, PDA refers to a broader cluster of traits, including a strong need for control, rapid mood changes, surface sociability, and use of social strategies to evade demands. The eponymous avoidance is not wilful opposition but an involuntary interpretation of perceived demands as threats which trigger the adrenal defense cascade.

Does it have other names?
The term Extreme Demand Avoidance (EDA) was put forward by O’Nions et al in 2013. EDA doesn’t differentiate between PDA and autistic avoidance (see below).
Persistent Drive for Autonomy (an alternative for PDA) was proposed by Cat and Wilding in 2018, but has been criticized for downplaying the role of demand avoidance in PDA behavior.

Is PDA a real condition?

Although empirical research is lagging, multiple evidence for PDA is provided by professional clinical observation and lived experiences, thus meeting two of the three parameters of evidence based practice.

What is internalized PDA?

Internalized PDA is identical to non-internalized PDA but signs of stress and distress are concealed (for example, holding in meltdowns, and maintaining a placid facial expression when experiencing significant pain).

Is PDA a psychological disorder?

No, PDA is a neurodevelopmental condition. However, lack of appropriate support can lead to emotional dysregulation and chronic mental health issues, including anxiety, depression, self-harm, and suicidal ideation.

How should PDA be diagnosed?

The diagnostic process should take into account that PDA is a complex condition with traits that may be internalized.

Diagnosis of children should involve a clinical psychologist, a speech and language therapist and an occupational therapist.

Diagnosis of adults should canvas the client’s perception of why PDA-like behaviors, such as avoidance, have been carried out in order to distinguish PDA from extreme demand avoidance.

Can PDA be diagnosed via the DSM-5?

The DSM-5 allows for PDA to be diagnosed as a behavioral description within a diagnosis of autism spectrum disorder (for example, “ASD with PDA behavior”). 

Prior to the DSM-5 (2013) PDA fitted the diagnostic category of Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS). However, the DSM-5 substituted PDD-NOS alongside separate autism categories for the newly-created umbrella category of autism spectrum disorder.

Is there an assessment scale for PDA?

There are several scales for measuring PDA. Of these, the PDAQ and EDA-8 are designed for children and may not fully represent  PDA. 

An informal adult PDA scale is available on the PDA Insiders website.

Is PDA autism?

Although the DSM-5 allows for PDA to be diagnosed as a description within an autism spectrum disorder diagnosis, there are key differences in the ability to read social-nuances and in benefitting from specific strategies (see below).

Is pathological demand avoidance the same as autistic avoidance?

Although some sources use the term PDA and autistic avoidance interchangeably, autistic avoidance has rational causes (e.g., sensory overload or transition issues) which resolve if traditional autism strategies are used, and doesn’t comprise PDA’s broader traits cluster.

What strategies work for PDA?

PDA requires markedly different strategies from general autism. They include respectful humor or role play to deflect stress, minimizing adrenal triggers, offering limited choices to preserve control, being emotionally honest, and practicing empathy. Reducing—rather than eliminating—demands while maintaining essential boundaries is key.

Is PDA often misdiagnosed?

PDA is a dynamic disability (meaning what someone can do in one time and place they may not be able to do elsewhere, even if conditions are the same). Instinctive use of social strategies can mimic personality disorders, willful non-compliance, and/or blamed on poor parenting. Also, PDA does not fit the standard diagnostic criteria used for diagnosing autism.

Is PDA used as a Fabricated or Induced Illness (FII)?

There are numerous reports of parents of PDA children being accused of FII, but FIIs are usually well-known conditions which medical professionals will find plausible.

Why not just use discipline?

Relying on discipline assumes that given the proper motivation, PDA behaviors will resolve. PDA-type avoidance, however, is involuntary and actually likely to increase if pressure is applied via discipline.

But if a demand is unavoidable, won’t they just give in?

PDA people can sometimes temporarily push through demand avoidance, but if appropriate support and rest are not eventually offered, cumulative stress will lead to burnout or extreme dysregulation.

Does PDA affect learning in school?

PDA does not affect intelligence, but it does impact a child’s ability to integrate within school systems. A 2018 survey carried out by the UK’s PDA Society found that 70% of PDA children were not in school. 

Friction can stem from inherent demands (for example punctuality, dress codes, hierarchy, and confinement) as well as peer alienation, which may worsen at around eight years when social communication gains complexity for neurotypical children, leaving PDA children lagging.

An IEP (individualized education plan) is one way to try to provide accommodations in the mainstream learning environment. Some families choose to homeschool so that they can offer better flexibility.

Does PDA affect employment?

Data from a 2016 peer study and accounts from lived experiences suggest that unemployment in the adult PDA population corresponds to the 70% of school non-attendance experienced by PDA children.

Specific employment issues include distress from workplace confinement; deadlines; and ceding control to bosses and managers; compounded by not being motivated by money.

What are the long-term health effects?

PDA adults and children are experiencing an invisible mental health crisis (PDA Society, 2023) involving anxiety, depression, low self-esteem, isolation or oneliness, self-harm and suicidal ideation.

Physical health may be compromised by avoidance of healthcare, including for life-threatening conditions.

What accommodations aid access to healthcare?

Accommodations that may help include: communicating in their preferred way (such as by email or SMS),  expediting waiting times, providing a quiet waiting area, providing choices (e,g., you could have X treatment or choose not to), explaining the purpose of non-negotiables, keeping them informed of what is going on, allowing a friend or family member to accompany them to appointments.

How many people are affected?

PDA is believed to be very rare, and that some diagnoses mistake PDA for extreme demand avoidance (see above).

However, growing awareness of the internalized presentation suggests PDA may be more common than some clinicians believe.

At what age does PDA start?

PDA is present from birth, although babies may be passive and first show signs of PDA after babyhood when etiquette and other demands are imposed.

How is PDA treated?

As it is a neurodevelopmental condition, PDA isn’t treated but can be supported. Collaborative approaches, adjusted lifestyles that allow more flexibility and rest, make PDA people able to function at their best.

Is PDA a disability?

PDA is essentially disabling because the brain stops beneficial actions, even those the person is otherwise capable of doing (e.g., drinking when thirsty, toileting, tasks they enjoy).

This means that PDA people cannot function well without support. Most PDA children require Individualized Education Plans (IEPs) in order to participate in mainstream school. PDA adults often require accommodations to work in jobs.