Pathological Demand Avoidance in Kids

All kids avoid doing things they’re asked to do from time to time. But some go to extremes to avoid or resist anything they perceive as a demand. Avoidance can take many forms, including making excuses, creating a distraction, intense focus on something else, withdrawing, escaping, or having a meltdown or panic attack.

That pattern of behavior is called pathological demand avoidance, or PDA. It is seen most often in people diagnosed with autism spectrum disorder.

People with PDA tend to have an adverse reaction to being told how to behave or what to do, even when it’s something that’s an ordinary part of their daily life — and even when it would benefit them. It’s called pathological when the avoidance is extreme and interferes with functioning at home or at school.

In kids who fit the PDA profile, resistance is sometimes mistaken for willful defiance, says Cynthia Martin, PsyD, clinical director of the Autism Center at the Child Mind Institute. But it’s better understood as a result of anxiety and inflexibility. As she explains, “Any external demand that is coming from somebody else, or that the person perceives is coming from another person — that generates a lot of internal discomfort, which leads to the avoidance.”

Tasks like putting on shoes, getting dressed, sitting down at a table, drawing, or saying the names of common items or pictures in a book may all be things a young child has the skills to do. But a child with PDA might only do these things when they’re personally motivated to do them. Experts call this “self-directed behavior.” The parent can ask, show, and direct all they want, but their child will not do it when another person asks them to. This can be a frustrating experience for parents – especially when their child is being evaluated, because the child may appear unable to do things parents know they can do.

Similarly, older children and adolescents may appear to have difficulty completing basic school assignments, even though parents know them to be capable of advanced academics.

Many children with autism spectrum disorder are inherently inflexible in their behavior and have rigid patterns of thinking, Dr. Martin adds. They are less tuned into social communication than other kids, so when a demand or expectation is placed on them, it can feel like it came out of nowhere.

While neurotypical kids do many routine things because they’re expected to or because that’s what everyone else is doing, autistic kids might not feel the same motivation to fit in. And rigidity may make them uncomfortable going with the flow.

For example, she says, take the situation in a classroom. “For many kids, it’s clear that the teacher is the one in charge. They understand that they need to do what the person in charge is telling them to do, and most everybody else is doing that as well.”

That’s social learning, she explains, where kids are just naturally tuning in to things other people are tuning in to and learning things without having to be directly taught. “But we know with autism there is a disconnect in that type of social learning. So, kids with autism will be less likely to go along to get along.

In school, this can lead to perplexing behaviors.  “Even a child with a very, very high IQ, who is in a mainstream setting, as they should be, and has no trouble doing math, may be thinking, ‘Everybody’s doing this math worksheet. I don’t want to do that, so I’m going to draw sharks instead, because I like sharks.’ The teacher’s going to come by and say, ‘You need to do your math,’ and the child might respond by saying no or getting upset, which could escalate to the child flipping their desk over.”

Poor executive functioning can be another trigger for PDA, since it makes it hard for kids to grasp the schedule or structure in a social environment. That means they don’t anticipate expectations that are not of their choosing.

“So for the child who’s drawing sharks rather than doing a math worksheet,” Dr. Martin explains, “he might feel that the teacher asking him to do his math comes out of nowhere. To shift from what he wants to do to something that somebody else wants him to do, out of the blue, is very challenging.”

Dr. Martin sees demand avoidance behaviors in many children with an autism diagnosis, at all kinds of levels — “kids with an IQ of 140 as well as kids with an IQ of 50.” But she thinks PDA traits also show up in kids who aren’t on the spectrum. And she reports that families are increasingly asking whether their child might have PDA and not autism.

Dr. Martin sees PDA behaviors as analogous to sensory processing challenges. Although sensory challenges are very common in autistic kids and are now considered a symptom of autism spectrum disorder, a child can have sensory issues without autism. This includes kids with ADHD and kids with no diagnosed developmental disorder.

“With PDA,” she says, “these are traits that will be in our broader population, too. And just like with any kind of trait, you’re going to have variability in the population, with some people having more of those traits than others.”

While some experts are pushing to recognize PDA as a standalone diagnosis, or a subset of symptoms of autism, others feel it is too vague to be clinically helpful.

The value in identifying PDA behavior as a “profile,” Dr. Martin argues, is to respond effectively to a child’s individual needs, as kids with PDA symptoms may need a different type of support than some other children on the spectrum.

Some strategies for working with kids on the autism spectrum don’t work effectively with children who have PDA behaviors. These children don’t respond as positively to direct communication about what is expected of them, which can trigger anxiety and avoidance. Instead, a collaborative approach with negotiation can make them feel more in control and less anxious.

The key is to find out what the child is motivated by, says Dr. Martin. Then you can spark that motivation and build on it.

It’s easy to assume that a small, routine task shouldn’t be that big of a deal. “But from a neuro-biological standpoint, that may be asking the child to climb a mountain,” says Dr. Martin. “We want to get them to climb the mountain, but we need to create steps in the scaffold for them to get up there.”

The goal is to avoid butting heads with the child, which tends to escalate the resistance without building the skills the child needs.. “We have to find what the child is  motivated by and be creative and flexible in our implementation,” she explains. “Suppose the child is interested in  sharks or cataloging music playlists. In that case, we’re going to build sharks or cataloging into the intervention, to increase the child’s own motivation to complete the thing that we want them to do.”

Some autism advocates feel that calling a child’s avoidance of demands on them “pathological” could violate their autonomy. But, Dr. Martin notes, a big focus in working with kids with PDA behaviors is on building what are called “adaptive skills” — skills that will improve their quality of life and ability to live independently.

“We’ve known for decades that individuals with autism have a big discrepancy between their IQ and adaptive skills,” explains Dr. Martin. “These kids aren’t performing ordinary daily tasks, even though they have shown that they know how to do them. This leads to being dependent on parents and other caretakers despite their capacity to do things themselves.” Often parents perform tasks for kids on the spectrum long after other kids are doing things independently, she adds, thinking they’ll grow out of their dependence. But they may not, if they have been successful avoiding demands for a long time.

Establishing clear consequences when kids don’t comply with demands is important. But, she notes that changing what leads up to the avoidance — harnessing motivation for the child to comply and encouraging flexibility — is more effective as a tool to increase compliance in kids who fit the PDA profile. “We also may need to taper our expectations for what ‘compliance’ will look like because a neurodiverse child with autism may do things differently, so we cannot confuse those differences as being non-compliant.”

Programs like Unstuck and on Target work on building flexibility in behavior and decreasing some of the intense emotional responses kids have to demands placed on them. “To build flexibility, we have to teach the child that there are benefits to being flexible — they will get what they want more often and have more time for the things they want,” Dr. Martin explains.  

This can involve learning ways to come up with a plan B when plan A does not work, how to compromise with others, and how to identify “choice” vs. “no choice” types of situations. When the child can have a lot of options within “choice” situations, they will likely be more likely to compromise and work with an adult to develop alternative plans in “no choice” situations.

Dr. Martin reports that kids with PDA make more progress and maintain it over time when they see that their ideas are considered. “When we are only taking a heavy behavioral approach, where it’s very reward-and-consequence driven, we often see treatment effects that are high initially, but then taper off over time.”