Pathological Demand Avoidance (PDA) is a term that has sparked significant debate and intrigue in the world of autism research and parenting communities. While PDA is gaining recognition, there is still a great deal that is not understood about this behavior profile, which is often considered part of the autism spectrum. In this blog, we’ll explore what we know about PDA, what remains uncertain, and the controversy that surrounds its recognition as a distinct condition within the autism spectrum.

What we know about PDA and autism

Pathological Demand Avoidance is a term first coined in the 1980s by UK-based researchers Elizabeth Newson and colleagues. PDA is described as a behavioral profile within autism characterized by an extreme resistance to everyday demands and expectations, often driven by anxiety. Children with PDA display behaviors that can appear challenging, including:

  • Refusing requests: Children may reject any form of demand, even those that appear relatively simple or benign.
  • Excessive control-seeking: A child might engage in behaviors that aim to gain control over situations, often in a manipulative or disruptive manner.
  • Mood swings and aggression: Children with PDA may experience rapid emotional shifts, sometimes lashing out when confronted with demands or pressure.
  • Social strategies to avoid demands: For example, children may use charm, distraction, or even physical illness as a means to avoid tasks.

PDA is considered part of the autism spectrum because it shares many traits with autism, such as social communication difficulties, sensory processing differences, and restricted interests. However, its hallmark feature is an extreme and pervasive need to avoid demands, which sets it apart from other autism profiles.

Research has shown that PDA is not a behavioral disorder, but rather a neurodevelopmental difference within the autism spectrum (O’Nions et al., 2014). Individuals with PDA are often highly intelligent, can be socially skilled when they wish to be, and may have a very specific set of interests that they focus on intensively. These strengths, however, can be overshadowed by the anxiety-driven demand avoidance behaviors.

What we don’t know about PDA and autism

Despite growing recognition of PDA, there is still much that is not fully understood about this behavior profile. One of the biggest uncertainties revolves around whether PDA should be considered a separate condition within the autism spectrum or simply a manifestation of autism itself. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), used by clinicians in the United States to diagnose autism, does not include PDA as a distinct condition (American Psychiatric Association, 2013).

This raises several questions:

  • Is PDA a subtype of autism or a separate condition? Some researchers argue that PDA is a distinct entity, while others believe it is best understood as part of the broader autism spectrum (Gillberg, 2014).
  • What are the underlying neurological mechanisms of PDA? While PDA is often linked to anxiety, the exact neurological basis remains unclear. Further research is needed to understand how the brain processes demands and why individuals with PDA experience such heightened anxiety in response to everyday expectations.
  • What is the most effective way to support children with PDA? The approaches to managing PDA are varied, with no consensus on the best treatment strategies. Behavioral interventions, which may work for some individuals with autism, may not be as effective for those with PDA. Instead, strategies that reduce pressure and allow for greater autonomy are often recommended, but these approaches need more empirical backing.

The controversy surrounding PDA

The controversy surrounding Pathological Demand Avoidance (PDA) stems from its lack of recognition in official diagnostic manuals and differing opinions on whether it should be considered a distinct condition within the autism spectrum. Some clinicians and autism advocates argue that PDA is an important and valid profile that deserves recognition and research, while others feel it is simply an exaggerated form of demand avoidance seen in some autistic individuals.


One of the key areas of disagreement is whether PDA is truly separate from other autism profiles, such as those characterized by repetitive behaviors and social communication difficulties. Some experts assert that the refusal to comply with demands is not an isolated condition but a coping mechanism driven by anxiety, a common feature in many autistic individuals. Others argue that the behaviors associated with PDA—such as using manipulation or strategies to avoid tasks—are so distinct that they should be classified as a separate condition.


Importantly, there are also perspectives within the autistic community itself that challenge the validity of PDA as a distinct condition. Some autistic individuals feel that PDA is not a helpful or accurate way to describe certain behaviors, especially since many of the behaviors associated with PDA—such as avoiding demands or controlling situations—are seen in various forms of autism. Critics within the autistic community argue that framing demand avoidance as a separate condition could further pathologize and complicate the experiences of autistic people, particularly those who may not identify with or relate to the PDA profile. They also raise concerns that PDA could be misused to justify a lack of support or understanding for other autistic individuals whose behaviors are similarly driven by anxiety but do not meet the PDA criteria.


In the UK, PDA has gained more recognition, with clinicians and support organizations advocating for its inclusion in official diagnostic criteria. The National Autistic Society and other advocacy organizations have recognized PDA as a legitimate profile within autism, though it is not yet universally accepted. On the other hand, many professionals in other countries, particularly in the United States, remain hesitant to officially diagnose PDA, mainly due to the absence of clear diagnostic criteria and the uncertainty surrounding its classification.

Why the controversy matters

The controversy over PDA’s classification is not just academic—it has real-world implications for families and individuals seeking support. Without official recognition in diagnostic manuals like the DSM-5 or the ICD-10, children with PDA may face difficulties in accessing appropriate support, accommodations, and services. This can lead to frustration for both parents and professionals trying to understand and meet the needs of children with PDA.

Additionally, the lack of consensus around PDA’s definition can lead to misdiagnosis or misunderstandings. For example, behaviors associated with PDA, such as resistance to demands, can sometimes be mistaken for oppositional defiant disorder (ODD), which is a different condition altogether. This can lead to inappropriate interventions that do not address the underlying anxiety and demand avoidance at the core of PDA.

Moving forward: What needs to change

While there is still much to learn about PDA, several key steps can help move the conversation forward:

  • Further research: More studies are needed to better understand the neurological underpinnings of PDA and to develop diagnostic criteria that are universally accepted.
  • Clearer diagnostic guidelines: Inclusion of PDA in future editions of the DSM or ICD could help ensure that children with PDA receive the appropriate diagnosis and support.
  • Awareness and advocacy: Increasing awareness of PDA among clinicians, educators, and parents is crucial to ensuring that individuals with PDA get the support they need to thrive.

Pathological Demand Avoidance remains a complex and controversial topic within the autism community. While much has been learned about this behavioral profile, there is still much to discover, particularly about its causes, diagnostic criteria, and the best approaches to intervention. What’s clear is that individuals with PDA deserve recognition, understanding, and appropriate support to help them navigate the world. As research progresses and awareness grows, we can hope for greater clarity and better outcomes for individuals with PDA and their families.

References

  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.
  2. Gillberg, C. (2014). Autism and PDA: The case for considering a distinct diagnosis. The Lancet Psychiatry, 1(2), 121–123. https://doi.org/10.1016/S2215-0366(14)70319-6
  3. Newson, E., Le Maréchal, K., & David, C. (2003). Pathological demand avoidance syndrome: A collection of essays. Routledge.
  4. National Autistic Society. (2020). Pathological Demand Avoidance: Understanding the PDA Profile. Retrieved from https://www.autism.org.uk/
  5. O’Nions, H., Fox, S., & Poon, C. (2014). Pathological Demand Avoidance: The state of the evidence. Journal of Autism and Developmental Disorders, 44(11), 2683–2697. https://doi.org/10.1007/s10803-014-2142-x