Pathological Demand Avoidance: Characteristics & Treatments

What Is Pathological Demand Avoidance?

Coined in the 1980s by British psychologist Elizabeth Ann Newsom, PDA isn’t a formal diagnosis in the DSM-5, but a subtype of autism that is gaining more recognition. All PDA individuals are autistic and can share common traits with members of the autistic population, including differences in communication, social interaction, sensory needs, and special interests or stimming; however, PDA also presents with more subtle social differences.^1,2,3

PDA individuals express that while they may want to meet demands or expectations, they’re unable to do so. Ordinary tasks, such as eating in response to hunger cues or following directions in class, can invoke a sense of anxiety or dread, preventing the individual from meeting the demand. Sometimes they will “freeze” or find themselves in a state of fight or flight. In other cases, they may do the opposite of, or anything but, what would be an expected response.²

Because PDA individuals may not fit certain stereotypes about what autism is thought to “look” like, it isn’t uncommon for them to go undiagnosed/misdiagnosed for longer periods of time. Missed diagnosis or misdiagnosis is especially common for autistic girls and women who fit the PDA profile.⁴

Strengths of PDA Autism

PDA autistic individuals can be innovative, independent thinkers and often possess the trait of being autodidactic, preferring to learn on their own.^5,6 Other strengths of PDA individuals include being sensitive, highly empathic and intuitive, determined, compassionate and humorous.⁷

In a shift away from viewing demand avoidance as purely pathological, PDA autistic adult and educator, Harry Thompson (as cited by Dr. Donna Henderson) often describes PDA instead as a “persistent drive for autonomy,” where any perceived threat to autonomy invokes an extreme anxiety response and action in an attempt to preserve it.^5,6

PDA vs. Oppositional Defiant Disorder

Autistic children who fall under the PDA profile are often misdiagnosed as having oppositional defiant disorder (ODD). These profiles may look similar but are actually quite different and require different approaches. First, PDA is a presentation of autism, and PDA individuals will possess other autistic traits such as sensory issues, difficulty with executive functioning, or social differences.⁸

While ODD can have genetic and neurobiological factors, oppositional behavior in those with ODD is thought to stem from thoughts and emotions that may be angry or “negative” in nature, whereas PDA resistance to demands is a result of neurological wiring and brain chemistry.⁸ As PDA self-advocate Harry Thompson expresses, “ODD is more of an ‘I won’t.’ PDA is more of an ‘I can’t.’”⁹

Characteristics of PDA Autism

Many autistic PDA individuals fly under the radar of an autism diagnosis because they don’t match stereotypical autistic traits. One of the primary characteristics looked for during autism assessment is a difference in or difficulty with social interactions. Often, PDA autistic individuals may have more subtle social differences. They may also be adept at masking or camouflaging social differences.

Here are common traits and characteristics shared by PDA individuals:^1,2,10,11,12

• Need for autonomy and control
• Resists demands of everyday life
• Might even resist preferred activities or activities the person enjoys
• Might be a passive, watchful observer in the first year
• May not recognize hierarchy
• Use of fantasy as escape or avoid demands
• Might appear interested in socializing but have difficulty interpreting social interactions or situations
• Difficulty with emotional regulation or mood swings
• Sensory differences, including sensory seeking, sensory sensitivities or even sensory processing disorder (SPD)
• Impulsivity or difficulty with self-regulation
• May have special interests or seem to have a “one track mind”
• Special interest might be a person, either real or fictional
• Might play pretend or be comfortable with role play
• Requires novelty and flexibility
• Autistic meltdowns or shutdowns

Treatment Options For Pathological Demand Avoidance

Autism doesn’t necessarily require treatment, but there may be areas of struggle for which an autistic PDA individual may benefit from specific support. Areas of need include sensory support, help with identifying emotions or managing anxiety, or support with speech and communication. Because preservation of autonomy is crucial for PDA individuals, approaches that support autonomy, agency, and self-advocacy are most helpful.¹¹

Because PDA has a strong component of anxiety, counseling or therapy can help identify triggers and offer coping strategies. Sometimes just talking to a supportive professional who understands can be important. For counseling or psychotherapy, working with an autistic, neurodivergent, or neurodiversity-affirming provider may be most helpful.

Although many autistic folks benefit from structure and routine, structure imposed by others can feel like a demand and threat to autonomy for the person with PDA.¹¹ Instead of a fixed, imposed schedule or routine, allowing the individual as much choice, freedom, and autonomy over their lives as possible can be beneficial. Facilitating autonomy while providing gentle support can be instrumental.¹³

Other forms of therapy to help support PDA autism include:

• Hippotherapy (therapy with horses)
• Music therapy
• Art therapy
• Speech and drama classes

As with other autistic folks, time alone and respite from social interaction can be necessary to restore and recharge one’s energy. Also, time, space, and encouragement for the person to pursue and learn about their own hobbies or special interests can help them achieve overall balance and well-being.

Final Thoughts

Pathological demand avoidance is an autistic profile that comes with unique strengths and challenges. Identifying PDA can facilitate increased understanding, allowing us to better honor and support the needs of each PDA individual.