Experts Explain Pathological Demand Avoidance

Do you think you or your child may be experiencing pathological demand avoidance? Read on to learn more.

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Do you often struggle with demands like deadlines or appointments? Maybe you find yourself freezing up the moment someone asks you to do something, even if it’s something you genuinely want to do. Or, maybe you’re a parent whose child frequently has meltdowns when you ask them to complete an ordinary task, like brushing their teeth or doing homework.

In these cases, the behavior could be due to pathological demand avoidance, or PDA. PDA describes a specific pattern of anxiety-driven behavior in response to demands that can make everyday expectations feel extremely overwhelming. This can affect kids and adults alike.

Read on to learn more about pathological demand avoidance, its connection to neurodivergence, how it presents in children and adults, how to cope, and more.

What is pathological demand avoidance?

“Pathological demand avoidance (PDA) is characterized by an intense, anxiety-driven avoidance of everyday demands, even those that seem simple or routine,” says Chris Hinton, LPC, a Group Facilitator at Charlie Health. 

Essentially, ordinary demands or tasks that most people can complete without much thought (such as answering an email or starting a basic household chore) can feel threatening for someone with PDA. This avoidance isn’t rooted in stubbornness or defiance; rather, it stems from anxiety and a need for control. 

It isn’t just external demands that cause anxiety, but internal demands, too. For example, PDA individuals might view hunger, thirst, or needing to go to the bathroom as internal demands. Even if they know they’re hungry or need to use the bathroom, they may delay taking action because responding to that need feels like another form of pressure, even though it’s coming from their own body.

British psychologist Elizabeth Newson coined the term in the 1980s after studying autistic children who exhibited strong avoidance behaviors that didn’t fit neatly into existing diagnostic categories. In a 2003 paper, she proposed “pathological demand avoidance syndrome” as its own separate diagnosis. 

Pathological demand avoidance is not an official diagnosis recognized in diagnostic manuals such as the DSM (Diagnostic and Statistical Manual of Mental Disorders) or the ICD (International Classification of Diseases). Today, PDA is most commonly characterized as a behavioral profile often associated with autism, says Hinton.

“Overall, the profile combines demand avoidance, anxiety, social complexity, and emotional intensity in a way that is distinct from other autism profiles,” Hinton says. 

Newer terms for pathological demand avoidance 

Other newer terms for pathological demand avoidance are “pervasive drive for autonomy” and “persistent drive for autonomy.” Some people prefer these terms since the word “pathological” can feel stigmatizing, and “drive for autonomy” helps explain that these behaviors are often rooted in a need for control and feelings of safety, not an intention to be difficult.

Pathological demand avoidance symptoms

While symptoms differ from person to person, most people with PDA share a common theme: feeling a strong need to avoid or escape demands, especially when they feel pressured.

According to Hinton, classic PDA symptoms include:

• A strong need for autonomy and control
• Significant distress when feeling pressured or directed
• Using strategies to avoid demands, such as distraction, negotiations, excuses, or sudden shifts in conversation
• Rapid mood changes, especially when demands feel inescapable 
• Struggling with deeper social expectations
• High levels of anxiety

PDA measuring tools

The main tool for measuring PDA traits is the Extreme Demand Avoidance Questionnaire (EDA-Q), created by Dr. Elizabeth O’Nions and her team in 2013. This served as a tool to quantify PDA traits in children and young people, listing 26 items relating to PDA. However, it is not an official diagnostic tool.

Regarding PDA in children specifically, there is a tool called the Extreme Demand Avoidance 8-item measure (EDA-8), which is a caregiver-report measure (meaning the caregiver fills it out about their child). This was developed in 2021 as a shorter tool featuring the main PDA traits.

Pathological demand avoidance checklist

You can view the Extreme Demand Avoidance 8-item measure as a “PDA checklist” of sorts. Again, this is not a formal diagnostic tool, but going through this checklist will give you an idea of whether your child may be dealing with PDA.

According to Dr. O’Nions and her colleagues, these eight items related to extreme avoidance behavior are:

• Obsessively resisting and avoiding ordinary demands and requests
• Driven by a need to be in charge
• Telling other kids how they should behave (but not applying the rules to themselves)
• Difficulty complying with demands (unless they’re carefully presented)
• Acting unaware of the differences between themself and authority figures, such as parents or teachers
• Rapid mood changes (such as switching from affectionate to angry quickly) 
• Using shocking or outrageous behaviors to get out of demands
• Extreme emotional responses to small events 

How PDA presents in children and adults

PDA can look very different depending on a person’s age, support system, and coping strategies. What begins as avoidance in childhood often becomes more internalized or complex in adulthood, sometimes leading to secondary mental health challenges.

Pathological demand avoidance in children

“In children, PDA often appears as an intense avoidance of everyday tasks that other children may not struggle with,” says Courtney Way, a Licensed Creative Arts Therapist at Charlie Health. “It is often misunderstood as defiance or rebellion, instead of being conceptualized as being PDA or anxiety-driven. These behaviors usually stem from anxiety or overwhelm and not from actual rebellion or defiance.”

Way says that some other signs of pathological demand avoidance in children are:

• Avoidance of tasks like getting dressed, brushing teeth, doing homework, and mealtime
• Struggling with transitions between tasks 
• Having meltdowns or shutdowns when they feel pressured
• Withdrawing when there are demands
• Trying to negotiate time limits with parents
• Asking to play games instead 
• Relying on fantasy, role play, or special interests to escape pressure
• Struggling with social boundaries
• Being sensitive to rejection
• Sensitivity to people’s tones or phrases when they perceive pressure 

Generally speaking, PDA makes ordinary things like schoolwork and social interactions feel overwhelming and even threatening, Hinton explains. “It can affect friendships, family relationships, and self-esteem, since the child may struggle to meet expectations that others see as simple,” she adds. 

Pathological demand avoidance in adults

PDA behavior often persists into adulthood, according to the PDA Society. “In adults, it often looks like an evolution of what you see in childhood,” Way says. “Many adults describe PDA as being a strong internal pressure that can make doing ‘simple’ tasks feel overwhelming, unsafe, or even threatening.”

She explains that some PDA characteristics in adults include:

• Difficulty with demands such as deadlines or appointments
• Struggling with self-care tasks
• Experiencing demand overload at work or in relationships
• Avoiding demands by procrastinating or delegating tasks
• Over-planning or having perfectionistic tendencies
• Masking distress related to demands
• Withdrawing from situations that they feel are demanding
• Struggling even with tasks they enjoy if it feels like something that requires immediate action

Due to all of these experiences, it’s common for adults with PDA to struggle to maintain traditional employment, Hinton says. “Deadlines, instructions from supervisors, or rigid routines can feel overwhelming or threatening, leading to avoidance, burnout, or frequent job changes,” she explains.

Furthermore, long-standing PDA can have a strong impact on an adult’s mental health, particularly in undiagnosed neurodivergent folks. “Adults with PDA can develop anxiety, burnout, feelings of shame, or depression from years of feeling misunderstood or unheard, especially if their neurodivergence is not recognized or supported,” Way says. 

The link between PDA and neurodivergence

PDA presents more commonly in neurodivergent individuals (particularly autistic people) compared to the general population. 

Pathological demand avoidance autism

Many clinicians view PDA as existing within the autism spectrum, though not all autistic people experience PDA, and not all people with PDA identify as autistic.

“Clinicians and other researchers often understand PDA to be something understood within the autism spectrum, making it a part of the spectrum itself,” Way says. “Unlike some more traditional presentations of autism, people who experience PDA may appear sociable on the surface level, or use humor to avoid demands, or sometimes mask their autism or autistic traits.”

Some autistic people with PDA may feel an intense “threat response” when a demand is placed on them, even if they logically understand the task is small. Heightened nervous system sensitivity may help explain why demands feel so overwhelming.

Pathological demand avoidance ADHD

“ADHD and autism can often co-occur, and it is common for individuals with ADHD also to experience PDA,” Way says. “When someone experiences both, they may experience anxiety-triggered avoidance and difficulty initiating tasks or transitioning to doing chores, which can make demands feel doubly overwhelming.”

However, it’s important to note a key difference between ADHD and PDA. “ADHD avoidance is often associated with difficulty shifting attention or focus or organization/transitions, whereas PDA avoidance is anxiety-driven,” Way explains. 

Pathological demand avoidance treatment

There are no formal, standardized, or evidence-based treatments for PDA, Way says. Instead, the focus should be on reducing demand anxiety and building autonomy, she says.

1. Trauma-informed and neurodivergent-affirming therapy

Working with professionals who are trauma-informed and neurodivergent-affirming is crucial since they will best understand how to help neurodivergent individuals with PDA.

“Therapists tend to work on anxiety management, sensory regulation, acceptance of neurodivergence, neurodivergent experiences, and emotional regulation rather than strict behavioral modification methods,” Way says. “More traditional, compliance-based methods that use rigid behavioral programs can increase distress and can worsen the avoidance and anxiety that comes with PDA.”

A therapist may also use cognitive behavioral therapy techniques to address extreme anxiety and unhelpful thought patterns that might further fuel the anxiety someone with PDA feels. 

2. Medication for pathological demand avoidance

There is no single medication to help treat the symptoms of PDA. However, medication can be used to manage co-occurring conditions like ADHD or anxiety. 

For example, stimulants or non-stimulant ADHD medications can help manage ADHD symptoms related to executive functioning. Antidepressant medications such as selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) can help treat anxiety disorders.

3. Getting support for school or work

Therapists and other professionals can help clients advocate for and receive tailored support at school or work. For example, Way says a child can get an individualized education plan (IEP) for additional help at school, or an adult can get workplace accommodations. 

Skills for managing PDA

Here are some practical skills that can help you or your child manage demand avoidance behaviors more effectively.

1. Parenting strategies

If you’re a parent to a PDA child, try to propose tasks as “low-demand” to reduce direct comments, Way says. This is sometimes called “low demand parenting,” which includes using indirect language, offering choices, and maintaining a calm tone. This can help the child feel less threatened by perceived demands. 

Additionally, consider Collaborative and Proactive Solutions models. “These strategies tend to be effective as they prioritize relationship-building, promote co-regulation predictability, and flexible expectations by using humor, calm environments, negotiation, and collaboration strategies,” Way explains. 

2. Low-demand starts

With low-demand starts, a person starts with the easiest and least threatening version of a task, Hinton explains. For example, they may sit next to the washing machine if the task is laundry, or open a document if they have to write something. This helps activation feel more manageable, Hinton says.

3. Five-minute permission timer

“Short, low-commitment approaches such as the five-minute permission timer also reduce anxiety by allowing the person to start with full permission to stop afterward,” Hinton says. So, pick a task and set a timer for five minutes. Commit to the task, but allow yourself to stop after those five minutes if you really want to, but you might find you have the momentum to keep going.

How Charlie Health can help 

If you or a loved one is struggling with PDA and mental health, Charlie Health can help. Charlie Health’s virtual Intensive Outpatient Program (IOP) provides more than once-weekly mental health treatment for people ages 8 through 64. We don’t view neurodivergence as something that should be “treated.” Instead, we believe it should be supported and affirmed, which is why we have a neurodivergent-affirming clinical curriculum.

Our expert clinicians incorporate evidence-based therapies into individual counseling, family therapy, and group sessions. With treatment, managing your mental health (or your child’s mental health) is possible. Fill out the form below or give us a call to start healing today.