Understanding Pathological Demand Avoidance (PDA)

Our expert psychologist Sharna Christie provides specialised support to help children with Pathological Demand Avoidance (PDA) overcome their overwhelming need to avoid everyday demands and expectations.

Introduction

Is your child resisting everyday tasks like brushing their teeth, putting their shoes on, or sitting down at their desk, with an intensity that leaves you scratching your head? If so, you have come to the right place. This isn’t just typical defiance; it is actually the child expressing a persistent drive for their own autonomy. Welcome to the world of Pathological Demand Avoidance or PDA.

In this post, we will be embarking on a journey together, diving into the complexities of PDA, its impact on individuals and families, and its relevance to psychology. We’ll also chat about strategies, particularly in the context of Australia’s National Disability Insurance Scheme (NDIS), for involving families, caregivers, and schools in supporting those with PDA.

What is PDA?

Pathological Demand Avoidance, or as it is more affectionately known as; Persistent Drive for Autonomy, is a profile on the autism spectrum. It’s characterised by an overwhelming and often overpowering need to avoid everyday demands and expectations. Very often, these are tasks that we would normally take for granted, like getting dressed, doing our hair, eating a balanced meal, or even getting into the car. Children who are experiencing PDA will also avoid the things that they enjoy doing, like riding a bike, going to the park, or doing arts and crafts, because of their PDA. This isn’t your run-of-the-mill defiance; it’s a profound, anxiety-driven response to any form of demand or expectation.

It is often thought that children with PDA are “difficult” “manipulative” or “stubborn” when this is simply not the case. PDA is distinguished from defiance by its unique link to anxiety, and more specifically, the fight, flight, freeze response. Ordinarily, this is a natural response designed to keep us safe in the face of danger. Our bodies gear up to protect us by either fighting the danger, running away from the danger, or becoming frozen on the spot with the hope that the danger won’t see us. 

Children with PDA experience this urge to protect themselves, but against daily tasks that threaten their autonomy and sense of independence. This means that ordinary, day-to-day tasks are triggering your child’s self-preservation instincts, leading to heightened anxiety. 
Imagine trying to face your most profound fears during every waking moment, while you are at work, or while trying to drive a car! This is what the PDA experience can be like for kids. 

Key Characteristics

• An intense need for control: Children experiencing PDA will resist anything that feels like a demand. This can be anything from refusing to get dressed or use the bathroom, to avoiding schoolwork, friends, and favourite activities.
• Social strategies to avoid demands: Children with PDA often use distraction, negotiation, or pretending not to understand as ways to avoid demands. They can also simply refuse to cooperate and will be very insistent that others comply with their own demands.
• Sudden mood changes: You may notice your child’s mood can switch rapidly from calm to extreme anxiety or anger, when faced with a demand. This can look like out-of-control emotions, sabotage, yelling and throwing things, using hurtful language and dominating others with the aim of avoiding the task. It can also look like aggression towards others and themselves. 
• Comfortable in role play and fantasy: Unlike other profiles on the autism spectrum, kids with PDA often engage very deeply in imaginative play as a form of escaping daily demands and anxiety.

Applicability to Psychology

Diagnostic Challenges

PDA can be tricky to diagnose because its characteristics overlap with other conditions like Oppositional Defiant Disorder (ODD) and other anxiety disorders. Seeking professional help is crucial in differentiating PDA from these conditions. This is done by conducting thorough assessments, observations, and interventions with the child and their support network. In Australia, psychologists use standardised diagnostic tools and collaborate with other health professionals who are a part of the person’s NDIS team, to ensure comprehensive, person-centred, and holistic evaluations are completed.

Intervention Strategies in Australia

Every child is unique, and just like autism, PDA is dimensional and often looks different for each person. Effective intervention strategies often involve a mix of behavioural strategies, environmental changes, and family support. In the end, the primary goal of any strategy should be to help your child reduce their anxiety and bolster their coping skills.

Things your psychologist might suggest for you and your child include:

• Offer them a greater sense of control: This can be done by giving your child the opportunity to say no, if possible, and the option to choose between two alternative tasks. This can also be achieved by giving your child control over parts of their daily routine such as whether getting dressed comes before or after eating or packing their school bag.
• Re-framing your language: This means rephrasing your requests in an indirect and conversational way to reduce the perceived pressure your child is experiencing. This might look like “I wonder if we can” “we could investigate” “when would you like to” and “how would you like to”.
• Make it fun: All kids love having fun! You can adjust how you and your child complete tasks by making up silly and imaginative games, or even by having a dance party! In a schooling environment, teachers might be able to do this by including friends, a buddy, or social games into the child’s daily curriculum.
• Creating supportive environments: By changing different aspects of the home and school environment we can minimise your child’s triggers and the things that are making them stressed. This might include; introducing progressive reward systems (this involves rewarding the child with a sticker, star, or tick on their chart each time they complete a desired behaviour, which provides them with an instantaneous incentive for their effort. Once they reach the agreed upon number of stars, they receive an agreed on major reward). An important detail here is that reward tokens are not removed or taken away once they have been earned. You could also introduce structured, achievable, un-timed tasks that the child usually enjoys, to improve self-confidence and independence. This may also look like the introduction of sensory toys and sensory modifications like weighted blankets, squeeze balls, wobble stools, and other sensory and emotional regulation items for your child to use.
• Regular psychological support: It is also important to have continuous therapy sessions to address your child’s underlying anxiety and to develop coping skills.
  

Involving Families and Caregivers

Education and Support

Supportive families and caregivers are an essential part of the team effort needed in managing PDA. As a NDIS service provider, we educate families, carers, teachers and other professionals about the PDA profile and provide practical strategies that can significantly improve your families’ outcomes. Workshops, support groups, and individualised coaching can empower families and teachers to support their little ones effectively.

Collaborative Approach

We take a collaborative approach that involves educators, therapists, families, and medical professionals to ensure that interventions are consistent and comprehensive. Regular communication and coordinated efforts help create a supportive environment for kids with PDA. In Australia, this often means working closely with schools to develop individualised education plans (IEPs) that accommodate the unique needs of students with PDA.

Real-Life Impact: Andre’s Story

Andre, a young boy with autism and PDA, began psychology because of his difficulties with getting ready for school, experiences of BIG emotions, and troubles in his relationships and home and at school. When I first started working with Andre, his struggles with his extreme need for control and autonomy posed significant challenges. He was very often angry and overwhelmed and would take his frustrations out on himself and the people around him. He was left feeling misunderstood and anxious most of the time. It was clear that a collaborative approach was needed, a team effort. We began by fostering an environment of empowerment and support for Andre and his family. With the help of Andre’s support coordinator, occupational therapist, behaviour support practitioner, school teacher and wellbeing officer, we were able to implement several strategies.

We worked with his school to implement an Individual Education Plan (IEP) that included sensory breaks, a quiet space for when he felt overwhelmed, and a reward system for small achievements. Structured opportunities for social play allowed Andre to foster strong connections with his peers and his need for control and dominance in social situations lessened. Andre’s parents were also given training and help in PDA-specific strategies, which allowed them to create a consistent and supportive environment at home. Over time, Andre's anxiety decreased, and his engagement in school, social activities, getting ready tasks at home, and enjoyment in his weekend activities with his family, all improved.

Call to Action

If this sounds like someone you know or you suspect that a loved one may have PDA, seek a professional assessment from a psychologist. Early identification and targeted intervention can lead to more effective support and better outcomes. In Australia, the NDIS provides funding options to support families in accessing these crucial services.