A Quick, Research-Based Intro to Pathological Demand Avoidance
A Short Review of This “aUtism Profile”, including its HIstory, Findings from Current Clinical Research, and a Few Resources
A significant number of my clients approach me suspecting they have “Pathological Demand Avoidance” (PDA). Since this is an idea that has a lot of traction on social media right now, I thought a brief overview of PDA might be helpful. This post will cover the history of the concept and what the most recent clinical research says about it.
What is Pathological Demand Avoidance?
Pathological Demand Avoidance (PDA) was first identified in the 1980s by psychologist Professor Elizabeth Newson. While assessing children for autism, she observed a distinct group with unique behavioral patterns. Newson (2003) proposed PDA as a specific “profile” within the autism spectrum with the following characteristics:
Resists and avoids ordinary demands of life
Strategies of avoidance are essentially socially manipulative
Surface sociability, but apparent lack of sense of social identity, pride or shame
Lability of mood, impulsive, led by need to control
Comfortable in role play and pretending
Obsessive behaviour
Nowadays, the PDA profile is described with slightly different and arguably less damning language. These “key features”, below, are quoted from the PDA Society, a registered legal charity whose mandate is to spread awareness of PDA:
Resists and avoids the ordinary demands of life
Uses social strategies as part of the avoidance
Appears sociable on the surface, but lacking depth in understanding
Experiences excessive mood swings and impulsivity
‘Obsessive’ behaviour, often focused on other people
Appears comfortable in role play and pretend, sometimes to an extreme extent (this feature is not always present)
Unlike Autism Spectrum “Disorder” (quotations included to underscore my disapproval of the descriptor “disorder”), PDA is not a category in the DSM-V, the most commonly used guide for diagnosing major psychiatric disorders. Nevertheless, the idea of PDA as a distinctive style of being autistic resonates with many autistic individuals and their families.
So, what does research tell us about PDA?
Is PDA a valid concept?
A systematic review of existing clinical research on Pathological Demand Avoidance in children and adolescents by Kildahl et al (2021) raises good questions. They state that research into the topic is limited by the lack of a consistent definition or means of measurement. Furthermore, certain researchers that they cite doubt that we should differentiate PDA from conditions like anxiety, which might already explain many of the behaviours linked to PDA. (More on that in a moment.) Overall, Kildahl et al assert that there is currently no clear evidence that PDA is a separate disorder or a stable subtype within autism.
Does that mean that the PDA profile is invalid? Not necessarily—because, of course, autism in general is under-researched. Just because our existing body of research does not make a compelling case for PDA does not mean that it does not exist. It can still hold value as a way of understanding certain autistic experiences; many families and individuals can attest to this.
However, I believe that better understanding the links that might exist between PDA, anxiety, and trauma makes sense. It helps us to approach behaviours that are associated with PDA with greater empathy—and clarity over how to help.
Links between PDA and other mental health Struggles
Some of the research cited in Kildahl et al’s systematic review suggests a strong link between Pathological Demand Avoidance and anxiety (O’Nions et al., 2018; O’Nions, Viding, et al., 2014; Stuart et al., 2020). Namely, the intolerance of uncertainty—commonly associated with anxiety in both autistic and non-autistic populations—may play a role in the emergence of PDA (Stuart et al, 2020). In other words, the autistic person may perceive a demand as a threat to their sense of control or predictability. That might spark enough fear that they use “social strategies”—from excuses to aggression to charm— to avoid the demand.
Furthermore, the avoidant behaviors associated with PDA may be partly driven by stress and trauma. To begin with, autistic individuals may perceive certain events—say, a shower or a walk to school— as markedly more stressful than neurotypical people might (Bishop-Fitzpatrick et al., 2017; Kerns et al., 2020; Kildahl et al., 2020b). This is complicated by the fact that caregivers and clinicians often struggle to recognize signs of distress or disorder in autistic individuals (Helverschou & Martinsen, 2011; Postorino et al., 2017). Miscommunication and misattunement between autistic people and their caregivers is often the result, and can become worse over time (Davis & Crompton, 2021). When this happens, autistic individuals who feel alone and misunderstood might respond with behaviors that are seen as inappropriate or disruptive (Mitchell et al., 2021).
A Few PDA Resources
Check out this PDA Society resource if you want a longer description of its key features.
