What is PDA?

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If you've found your way here, it is likely that you’ve encountered the term Pathological Demand Avoidance (PDA) and want to learn more. Although research and recognition of PDA are still in the early stages, awareness of PDA and its unique support needs is steadily increasing. People with PDA share a common cluster of traits that include heightened anxiety—often associated with autonomic nervous system responses, such as fight, flight, freeze, or fawn—in response to demands, even those that may seem routine or enjoyable (Gray & McNaughton, 2000; Stuart et al., 2020; Haire et al., 2024).

Insights from lived experiences and the PDA community often highlight how demand avoidance often relates to a perceived loss of autonomy. For individuals with PDA, demands or losses of autonomy may trigger a cascade of stress responses, impacting their ability to access activities, services, or navigate especially high-demand or compliance-based environments, like school. This understanding supports approaches that honor the autonomy and safety needs of individuals with PDA rather than focusing on compliance or behavior correction (Milton, 2013; Lim et al., 2024). While I am eager for more research, it is clear that there are already adults, children, and families who feel best understood through a PDA lens and who have benefited from approaches that address PDA-specific needs (Green et al., 2020; Haire et al., 2024).

PDA is characterized by an individual’s heightened avoidance of everyday demands and expectations, primarily as a response to extreme anxiety or heightened sensitivity to unpredictability (Green, 2020; Haire et al., 2024). These behaviors are best understood as stress responses that reflect an individual’s need to maintain autonomy and control over their environment to reduce perceived threats (O’Nions et al., 2016; O’Nions & Eaton, 2020).

Although PDA has frequently been studied as a profile within the autism spectrum, there is ongoing debate about whether PDA traits are exclusive to autism. While many individuals with PDA meet the criteria for autism, emerging evidence suggests that PDA-like behaviors may also occur across other neurotypes, particularly in conditions associated with anxiety and demand sensitivity, such as ADHD or certain mood disorders (Gillberg et al., 2015; Lim et al., 2024). Some researchers argue that PDA is best understood as a response to intense anxiety and "intolerance of uncertainty," which may manifest as demand avoidance in both autistic and non-autistic individuals (Stuart et al., 2020).

A key area of focus is whether PDA should remain within the autism spectrum or be seen as a distinct profile that intersects with autism but can also appear in other neurotypes. Currently, PDA is not formally recognized as a standalone diagnosis in the DSM-5 or ICD-11, which creates challenges for consistent identification and support.

• High Anxiety and Demand Sensitivity: PDA behaviors frequently reflect an intense stress response to demands, often linked to high anxiety or a heightened sensitivity to uncertainty (Stuart et al., 2020; Haire et al., 2024). 
• High Need for Autonomy and Equality: Individuals with PDA often exhibit a consistent drive to avoid perceived control from others and engage in behaviors aimed at ensuring a sense of agency and equality in interactions. These behaviors, while sometimes seen as oppositional, are better understood as adaptive attempts to maintain emotional safety in response to intense stress (Milton, 2013; Lim et al., 2024).
• Mood Variability: Individuals with PDA often experience rapid and intense mood shifts that may appear unpredictable, frequently triggered by perceived threats to autonomy or anxiety-inducing demands. Rather than being simple behavioral issues, these mood changes are best understood as adaptive responses to navigate environments that feel threatening or overly controlling (O’Nions et al., 2018a; Stuart et al., 2020).
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Rather than viewing PDA as merely defiant or oppositional, a PDA-affirming perspective considers these traits as adaptive responses to overwhelming anxiety. This understanding supports a roadmap for providing effective support that includes respecting autonomy, maintaining empathy and connection in response to stress behaviors, prioritizing demands based on the individual’s fluctuating capacity, and providing tools and strategies to manage anxiety, including autonomic nervous system responses.

References

• Gillberg, C., Gillberg, I. C., Thompson, P., Biskupsto, R., & Billstedt, E. (2015). Extreme ("pathological") demand avoidance in autism: A general population study in the Faroe Islands. European Child & Adolescent Psychiatry, 24(8), 979–984. https://doi.org/10.1007/s00787-014-0647-3
• Gray, J. A., & McNaughton, N. (2000). The neuropsychology of anxiety: An enquiry into the functions of the septo-hippocampal system. Oxford University Press.
• Green, J. (2020). Editorial: Demand avoidance—pathological, extreme, or oppositional? Child and Adolescent Mental Health, 25(2), 57–58. https://doi.org/10.1111/camh.12388
• Haire, L., Symonds, J., Senior, J., & D’Urso, G. (2024). Methods of studying pathological demand avoidance in children and adolescents: A scoping review. Frontiers in Education, 9. https://doi.org/10.3389/feduc.2024.1230011
• Lim, R., Yip, J., & Richardson, A. (2024). Parental experiences in the use of fluoxetine for managing disruptive behaviors in children and youth with autism and pathological demand avoidance: A mixed methods exploratory study. University of British Columbia.
• Milton, D. E. M. (2013). ‘Nature’s answer to over-conformity’: Deconstructing pathological demand avoidance. Autism Experts Online.
• O’Nions, E., Happé, F., Viding, E., Gould, J., & Noens, I. (2018a). Dimensions of difficulty in children reported to have an autism spectrum diagnosis and features of extreme/pathological demand avoidance. Child and Adolescent Mental Health, 23(4), 220–227. https://doi.org/10.1111/camh.12246
• O’Nions, E., & Eaton, J. (2020). Extreme/pathological demand avoidance: An overview.
• Stuart, L., Grahame, V., Honey, E., & Freeston, M. (2020). Intolerance of uncertainty and anxiety as explanatory frameworks for extreme demand avoidance in children and adolescents. Child and Adolescent Mental Health, 25(2), 59–67. https://doi.org/10.1111/camh.12367