Does your child rarely or never comply with your requests? Do they tend to avoid responsibilities and struggle to complete tasks that most kids would find agreeable? Do they procrastinate, shut down, or act out aggressively when you ask them to do something? If so, you might want to familiarize yourself with the symptoms of pathological demand avoidance (PDA). PDA is not an official diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Instead, it describes a set of behaviors and traits that can interfere with daily functioning. Pathological demand avoidance in kids also has its share of controversy and misunderstandings. Let’s look deeper at PDA’s characteristics, symptoms, and ways parents can cope. While most children will demonstrate defiant or avoidant behavior to some degree, PDA refers to persistent avoidance that interferes with daily life.

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WHAT IS PATHOLOGICAL DEMAND AVOIDANCE?

The term “pathological demand avoidance” was coined by British psychologist Elizabeth Newson as early as the 1980s. She made its official debut in the medical community through her 2003 review, “Pathological Demand Avoidance Syndrome: A Necessary Distinction within the Pervasive Developmental Disorders.” As the title suggests, Newson opined that PDA deserved to be recognized as its own entity rather than grouped into “pervasive developmental disorder not otherwise specified,” as it was in the then-current DSM-4. She also noted that PDA was found to be “significantly different on many counts from classic autism and Asperger’s syndrome.” Even today, PDA is closely linked with autism, since it’s most often seen in those with autism spectrum disorder (ASD). Experts have drawn connections between PDA and the challenges of sensory processing found in autism. But sensory challenges, as well as PDA, can be present without autism. Symptoms of PDA can also overlap with those of other mental health conditions, like attention-deficit/hyperactivity disorder (ADHD), complex post-traumatic stress disorder (CPTSD), or oppositional defiant disorder (ODD). And some children with PDA may have no diagnosed mental health disorders. Furthermore, when untangling the definition and diagnoses behind PDA, the National Autistic Society warns that very little research exists on this topic, “and the research that does exist is generally of a low quality. Because of this, many aspects of demand avoidance…are under-researched and often contested.” Even the name itself has been subject to controversy. Because of potential stigma surrounding the word “pathological,” alternative names have been suggested: persistent drive for autonomy, extreme demand avoidance, and rational demand avoidance.

SIGNS OF PATHOLOGICAL DEMAND AVOIDANCE

Kids with pathological demand avoidance may be mistakenly labeled as troublemakers or defiant. They may appear so, since they’re likely to resist demands from others—and even their own demands. But their avoidance is not related to laziness, willfulness, or lack of intelligence. Rather, those with PDA tend to struggle with anxiety and rigid, inflexible thinking. While most children will demonstrate defiant or avoidant behavior to some degree, PDA refers to persistent avoidance that interferes with daily life. For example, while it might be normal for kids to occasionally refuse to do their homework or chores, a child with PDA can freeze up in the face of simple questions. Or they may deny their own bodily cues, such as avoiding hunger or thirst. The PDA Society notes that demands can take many forms, from direct requests to general expectations. Children with PDA (a spectrum disorder) have a range of responses to those demands. Avoidance tactics may be exhibited externally (overt avoidance), internally (feelings of anxiety), or both. Because these children can show avoidance in response to big and small demands, they may have trouble with tasks such as:

• Completing schoolwork or chores
• Fulfilling their personal needs or desires
• Going to bed or waking up
• Making decisions, like choosing a meal from a menu
• Following instructions
• Answering questions

They can even avoid activities they genuinely enjoy, or struggle with making and keeping concrete plans. Ultimately, kids with PDA grapple with anxiety and a lack of control. Their responses can vary from distraction and procrastination to making excuses or escaping into fantasy. In more extreme reactions, they may run away, exhibit aggressive behavior or shut down. It’s easy to see why various challenges associated with autism could complicate or overlap with PDA. For example, those with autism may have difficulty with social cues, hierarchies, and communication, as well as with learning new skills. Pathological demand avoidance in autism can reinforce symptoms like rigid behaviors and sensory sensitivities.

COPING WITH PATHOLOGICAL DEMAND AVOIDANCE SYMPTOMS

When children with PDA are misunderstood as “bad” or “lazy,” they’re likely to perform even worse in school and at home. While it’s important for parents to set consequences for behavior, tactics like enforcing overly strict punishments or ramping up the intensity of demands are likely to backfire. Instead, you and your child can learn how to work with their abilities and limitations rather than against them. When dealing with your child’s oppositional behavior, the Child Mind Institute recommends strategies such as:

• Collaborating with your child on accomplishing tasks
• Avoiding arguing
• Using negotiation, compromise, flexibility, and creativity
• Finding and utilizing your child’s innate sources of motivation
• Helping them develop skills that will enable more independence
• Understanding that their compliance may look different than your expectations

If your child is struggling with the above symptoms, it might a good idea to have your child assessed for PDA and to rule out other conditions. Through thousands of brain scans using a technology called single photon emission computed tomography (SPECT) on children and adults with autism, Amen Clinics has pinpointed 8 to 10 suspected factors that can influence abnormal brain function leading to this developmental disability alone. Because mental health is brain health, a scan will help determine the underlying brain patterns behind the behaviors. Only then can an effective treatment plan be enacted, including tactics like:

• Behavior modifications
• Life skills training
• Nutritional supplements
• Sensory integration therapy

A targeted plan can improve the child’s future health and success while improving life quality for both the parent and child. Additionally, experts agree that PDA will benefit from further exploration within the medical community. A 2023 review noted that while PDA “is a behavior profile that can be associated with adverse illness progression and unfavorable outcomes,” it’s only “one feature in a complex model.” These researchers emphasize that each person will display pathological demand avoidance differently, but their caregivers and treatment decisions play a key role in helping those affected. Still, they concluded, “Substantial research is needed concerning the occurrence of the behavior profile PDA in diverse disorders, treatment options, and treatment responses.”

CREATING BETTER OUTCOMES FOR PDA

While pathological demand avoidance describes a set of behaviors that last throughout a lifetime, gentler approaches can make a world of difference in coping along the way. It’s crucial for parents and other authority figures to remain open-minded and nonjudgmental, rather than labeling these children as stubborn or defective. Learning and teaching them how to work with their differences will help prevent further hindrances to their performance. Using patience, understanding, and flexibility, you may change the course of their entire lives. Pathological demand avoidance and other mental health issues can’t wait. At Amen Clinics, we’re here for you. We offer in-clinic brain scanning and appointments, as well as mental telehealth, clinical evaluations, and therapy for adults, teens, children, and couples. Find out more by speaking to a specialist today at 888-288-9834 or visit our contact page here.