Pathological demand avoidance

The primary sign is an atypical resistance to normal, everyday social demands. For the purposes of PDA, a demand is social interaction or similar opportunity to cooperate, very broadly understood.^[11] It encompasses things that seem like demands, such as being told to do homework now, but it also includes everything from someone silently offering to shake hands to knowing that catching the bus requires leaving home in time to walk to the bus stop.^[11] All children are uncooperative from time to time, and this may be amplified during some developmental phases (e.g., the so-called "terrible twos"). However, children with PDA display a resistance to everyday demands that goes dramatically beyond typical behavior, until it interferes with their everyday lives, and their resistance is obsessive and extreme.^[12] The resistance to demands even applies to demands that they make on themselves, such as preparing for a self-chosen favorite activity.^[11]

When people with PDA perceive demands, they may use a variety of methods to avoid it. For example, they may try to ignore it or distract the person with a different subject.^[13] If the demand persists, they may strategically escalate to intentionally shocking behavior, such as [in children] deliberately kicking someone to get out of doing something; shame or remorse for such inappropriate or infantile behavior is often not communicated.^[14][15][13]

Additional associated features including:

• an appearance of social skills that are superficially acceptable but which have odd features, such as [in children] a belief that the normal rules apply only to other people, or that they have the same authority as adults or people in positions of authority;^[16]
• emotional
  lability, such as being affectionate one moment and angry the next, and impulsive and controlling behaviors;^[16]
• being comfortable with role-playing and pretending to be other characters.^[16] This may be used when trying to avoid a demand; and
• "soft" signs of neurological divergence, such as
  clumsiness.^[16]

A PDA profile is a spectrum of different features that a person may experience. Depending on a certain profile, the PDA can be considered internalized or externalized. Internalized PDA includes an individual being more quiet and reserved with their reactions when they are triggered. [17] Internalized PDA reactions are not less intense; rather, their reactions are hidden from public view. Furthermore, these individuals can experience more avoidance behaviors when their trigger came from an internal decision. ^[18] Externalized PDA includes an individual being expressive with their reactions when they have been exposed to a trigger. This could result in noticeable physical and mental differences such as meltdowns, panic attacks, being controlling, aggressive, and anxiety. ^[19][20]

Although PDA has its own traits that are separate from autism, people with PDA generally meet the diagnostic criteria by having significant difficulties in

• are more sociable
• have better social skills and social understanding
• use apparently socially manipulative and shocking behavior^[21][22]
• are more interested in people than objects
• are more comfortable with pretend play, and
• are more imaginative

The term was proposed in 1980 by the UK child psychologist

Diagnosis

PDA is not included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD). To be recognized, a sufficient amount of consensus and clinical history needs to be present, and as a newly proposed condition, PDA had not met the standard of evidence required at the time of recent revisions, however, patients that exhibited PDA behaviors were later diagnosed with autism using the DSM. ^[25]

As of 2014 there are no officially recognized diagnostic criteria.^[26] Observations in children with PDA that were identified as common features^[21] that potential possible diagnostic criteria could be based on include:

• Passive early history in the first year, avoiding ordinary demands and missing
  milestones
• Continuing to avoid demands, with panic attacks if demands are escalated
• Surface sociability, but apparent lack of sense of
  social identity
• Lability of mood and impulsivity
• Comfortable in
  role play
  and pretending
• Language delay, seemingly the result of passivity, often caught up quickly
• Obsessive behavior
• Use of apparently socially manipulative and shocking behavior^[21]
• Neurological signs (awkwardness, similar to autism spectrum disorders^[27])

The 26-item Extreme Demand Avoidance Questionnaire (EDA-Q) was designed for research, but has been used as an aid to diagnosis in school-age children. In 2021, this was reduced to an 8-item questionnaire (EDA-8).

Many of the studies published on PDA have methodological limitations, which restricts conclusions that can be drawn about patterns of behaviors characteristic of PDA. It is unknown how much demand-avoidant behaviors vary between children and how much they change as they grow up.[30]

Causes of demand avoidance

The underlying cause of demand avoidance in autistic children is said to be a high level of anxiety, usually from expectations of demands being placed on children, which can lead to a feeling of not being in control of a situation. Consequently, an additional diagnosis of generalized anxiety disorder or another anxiety disorder may be made instead of PDA.^[31] About 40% of autistic people suffer from an anxiety disorder.^[32]

Children with PDA feel threatened when they are not in control of their environment and their actions, which triggers the fight, flight or freeze response.^[33]

Recognition

In 2011, the National Institute for Health and Care Excellence (NICE) said that PDA has been proposed as part of the autism spectrum but did not include further discussion within the guideline.^[2] NICE guidance also expects an ‘ASD’ diagnosis be accompanied by a diagnostic assessment, providing a profile of key strengths and difficulties. Demand avoidance is listed as a ‘sign or symptom of ASD’ (Appendix 3).^[2]

Christopher Gillberg wrote in 2014 that “Experienced clinicians throughout child psychiatry, child neurology and pediatrics testify to its existence and the very major problems encountered when it comes to intervention and treatment.”^[34]

Naming controversy

Pathological demand avoidance has been criticized as a name for various reasons, including the negative connotations some confronted with the word