What is Pathological Demand Avoidance (PDA)?

Summary: Pathological demand avoidance (PDA) is a set of behaviors characterized by significant, disruptive resistance to any demand placed on an individual.

Key Points:

• Features of PDA are common in people diagnosed with autism spectrum disorder (ASD), including children, adolescents, and adults.
• Many people with ASD who show features of PDA prefer the phrases Extreme Demand Avoidance (EDA) or Demand Avoidance (DA) because they show some features of PDA but not others.
• PDA, EDA, and DA often overlap with defiance and conduct disorders, which are distinct from ASD diagnoses.
• In children, adolescents, and adults with or without ASD, stress, anxiety, and uncertainty can exacerbate the behaviors associated with PDA, which can lead to functional impairment in various situations.

How Experts First Identified PDA

Pathological demand avoidance (PDA) is not a standalone diagnosis in the two primary diagnostic manuals mental health professionals use worldwide – the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). It is, however, a term that clinicians working in mental and behavioral health use to describe a behavioral profile that can cause significant disruption in daily functioning, interpersonal relationships, academic achievement, and vocational performance and stability.

The term is not new. It has become more common in recent years, though, due to an increase in our understanding and recognition of the various features of ASD and people with conditions associated with neurodivergence.

The article “Methods of Studying Pathological Demand Avoidance in Children and Adolescents: A Scoping Review” describes the origin of the term pathological demand avoidance (PDA):

“The concept of PDA emerged in the 1970s when a clinician, Elizabeth Newson found children referred to her clinic for autism assessment resembled autistic children but were different from them and similar to each other. Newson and colleagues developed a set of criteria describing these children, the central feature being a need to avoid everyday demands to reduce anxiety, using social manipulation as a key strategy.”

The features of PDA are strongly associated with people with autism spectrum disorder. Evidence shows that roughly 20 percent of people with ASD also show features of PDA. However, a close reading of the original analysis of the behavior shows that children with PDA were “different from [children with ASD] and similar to one another.”

That’s why people in the ASD community, those who identify as neurodivergent, and people identified as having PDA advocate for phrases like extreme demand avoidance (EDA) or demand avoidance (DA). They’re distinctions with differences, they recognize nuance, and they reduce the likelihood pathologizing people rather than specific behaviors.

Let’s take a closer look at demand avoidance (DA) overall, including what people call PDA and EDA.

What’s Behind Demand Avoidance?

In an online resource published by the National Autistic Society, experts on ASD and neurodivergence define “Demand Avoidance” as follows:

“The characteristic of a persistent and marked resistance to ‘the demands of everyday life’, which may include essential demands such as eating and sleeping as well as expected demands such as going to school or work.”

The operative phrase in that definition is ‘the demands of everyday life.’ While people on the autism spectrum resist demands in specific situations, most often unannounced changes in routine or interruptions to preferred/enjoyed behaviors – and those demands may relate to the demands of everyday life, a person with EDA (or PDA) will resist or avoid any demand placed on them at all, for any reason, in any context.

People with EDA/PDA may use the following strategies to avoid the demands placed on them:

• Procrastinating
• Manipulating
• Negotiating
• Hurting themselves to prevent compliance
• Withdrawing or retreating to fantasy/playing imaginary roles
• Physical aggression

This is where it’s important to recognize nuances and differences within differences. In people with ASD, demand avoidance increases alongside perceived levels of stress and emotional discomfort.

It’s also important to interrogate the word ‘manipulating’ in the context of an ASD diagnosis. We’ll revisit this question later in this article.

While a person with ASD may resist demand in order to keep their preferred routine or manage escalating stress, a person with PDA/EDA – with or without ASD – displays different characteristics:

“[People with] PDA do not simply have extreme demand avoidance which is affected by stress levels. Their demand avoidance can apply to every single instance where they perceive a demand. This could be getting up in the morning, eating, drinking, going to see a movie that they have been really looking forward to going to, [or] playing with a new toy. It is uncontrollable and all encompassing.”

Pay attention to the phrase “uncontrollable and all encompassing.” People with PDA/EDA avoid all demands placed upon them. It’s an involuntary reaction. They don’t simply defy authority, as in oppositional defiant disorder (ODD). And they don’t simply say no to things they don’t want to do, which we all do at various times and for various reasons. They may avoid virtually all demands placed on their time, attention, energy, and behavior, irrespective of the nature of the demand.

Therefore, for people with PDA/EDA, we can answer the question “what’s behind the avoidance” by identifying a persistent behavioral characteristic to resist all demands. This may include a drive to avoid uncertainty, a desire to maintain personal autonomy, and a need to manage anxiety, whether they have an ASD diagnosis or not.

Defining Characteristics of Demand Avoidance in PDA and EDA

To better understand PDA in adults, we’ll present a framework assessed in the peer-reviewed journal article “The Measurement of Adult Pathological Demand Avoidance Traits,” published in 2018. In that review, researchers analyzed the validity of an tool called the “Extreme Demand Avoidance Questionnaire – Adult version (EDA-QA).” Clinicians adapted this tool from the “Extreme Demand Avoidance Questionnaire (EDA-Q), initially designed to measure demand avoidance in children and adolescents.

We’ll share the questionnaire itself. Then we’ll offer the conclusions the researchers reached about its validity and usefulness in the adult population. When reading the questions, consider the possible answers. Think about how clinicians score the assessment. Imagine how the answers might relate to what we know about ASD. Attempt to empathize with what it means to resist demands. Finally, assess how a high score on the questionnaire may predict the likelihood of experiencing disruption in daily life due to demand avoidance.

The EDA-QA: The Questions Give Us Answers

We retrieved the full Extreme Demand Avoidance Questionnaire for Adults (EDA-QA) from the website Embrace Autism: The Ultimate Autism Resource.

In the assessment, respondents choose one of four answers that apply to their personal behavior: (a) not true, (b) somewhat true, (c) mostly true, (d) very true. When clinicians score this scale, they assign numeric values of 0-3, corresponding with a-d. For questions 14 and 20, scorers reverse the values, with 3-0 corresponding with a-d, respectively. Although there is no clinically verified cutoff point for PDA or EDA, consensus indicates a score of 45 or more out of a possible highest score of 78 indicates a “high risk of showing features of PDA.”

The 26-Item EDA-Q: The Actual Questions, Unedited

1. I obsessively resist and avoid ordinary demands and requests.
2. I complain about illness or physical incapacity to avoid a request or demand.
3. I am driven by the need to be in charge.
4. I find everyday pressures (e.g. having to go on a routine trip/visit dentist) intolerably stressful.
5. I tell other people how they should behave, but do not feel these rules apply to me.
6. I mimic other people’s mannerisms and styles (e.g., use phrases adopted from other people to express myself to others).
7. I have difficulty complying with demands and requests from others unless they are carefully presented.
8. I take on roles or characters (from TV/real life) and ‘act them out’.
9. I show little shame or embarrassment (e.g., I might throw a tantrum in public and not be embarrassed).
10. I invent fantasy worlds or games and act them out.
11. I am good at getting around others and making them do as I want.
12. I am unaware or indifferent to the differences between myself and figures of authority (e.g. parents, teachers, and police).
13. I will still sometimes have a ‘meltdown’ (e.g., scream, tantrum, hit, or kick) if I feel pressurized to do something.
14. I like to be told I have done a good job.
15. I have a very rapidly changing mood (e.g., I can switch from affectionate to angry in an instant).
16. I know what to do or say to upset particular people.
17. I blame or target a particular person/persons.
18. I deny things I have done, even if I am caught “red-handed”.
19. I can be distracted (preoccupied) ‘from within’ (i.e., absorbed in my own world).
20. I make an effort to maintain my reputation with other people.
21. I sometimes use outrageous or shocking behavior to get out of doing something.
22. I have periods when I have extremely emotional responses (e.g., crying/giggling, becoming furious) to what others would think small events.
23. I ensure any social interaction is on my own terms.
24. I prefer to interact with others in an adopted role or communicate through props or objects.
25. I seek to quibble and change rules set by others.
26. I can be passive and difficult to engage.

Reading/reflecting on those questions is instructive. it’s not difficult to understand how a person who answers “3” on most of them may have difficulty interfacing with the world and many of the people in it. It’s also relatively straightforward to understand how this type of default extreme avoidance overlaps with, but may not be exclusive to, the characteristics of autism spectrum disorder.

Here’s how the authors of the study describe the validity of the ED-QA, after a thorough analysis and comparison with symptoms of ASD and mental health disorders/conditions associated with avoidance:

“Results indicate that the EDA-QA is internally reliable. It is consistent with peer ratings for adults who span a range in terms of self-identified behaviors. We conclude that the EDA-QA provides a solid methodological platform for more systematic research into adult PDA. [It may be effective] in a variety of contexts, particularly clinical ones. Such research could help improve the care and management of persons who self-identify as having PDA traits, seem unable to adapt to demands placed on them by adult life.”

We’ll close this article with suggestions from clinicians and researchers about how to help people with PDA/EDA/DA manage symptoms and navigate daily life.

How to Help Someone With Avoidant Characteristics

There is very little information about specific support strategies for people with significant demand avoidance, a.k.a. PDA/EDA/DA. However, testimony from people with the symptoms we discuss above includes the following suggestions:

1. Lead with empathy and understanding.
2. Help people with significant DA understand their condition, and what triggers avoidance.
3. Seek professional support from mental health professionals. Find those who advocate and apply a strengths-based approach to therapy and counseling people with mental health conditions. Prioritize therapists with experience in neurodivergence.
4. Reduce frequency of demands, if possible.
5. Take a collaborative, rather than authoritative or authoritarian approach, i.e. include them in the power structure related to the demand.
6. Consider inductive reasoning and indirect communication.
7. Be mindful of body language, tone, and quality of communication.
8. Enlist the support and participation of any relevant people: family, teachers, employers, and caregivers.

Supporting people with extreme or pathological avoidant characteristics can improve their daily lives in a variety of ways. It can increase their ability to take care of themselves and reduce symptoms of anxiety, panic attacks, and emotional distress. It can also increase their capacity to fully participate in school or work activities. Improvements in all of those areas can enhance overall wellbeing and help them move toward a healthy and balanced life.