What is Pathological Demand Avoidance?

What is Pathological Demand Avoidance?

Pathological Demand Avoidance (PDA) is a form of autism that may also affect the way a person communicates and relates to other people.

People with PDA may experience challenges such as specific learning difficulties, but their central difficulty is that they are driven to avoid everyday demands and expectations to an extreme extent. This avoidance is rooted in an anxiety-based need to be in control.

When Pathological Demand Avoidance was first documented

In 2003, Pathological Demand Avoidance was identified as many children seemed to have different symptoms that were not the norm and seemed puzzling. They didn’t fit the behaviour of a neurotypical child but didn’t show full-blown autistic tendencies either. They were imaginative and more sociable but in an odd way. Something was different and the fit between neurotypical and autism, with neither diagnosis seeming accurate.

This group of children displayed behaviour that was labelled “atypical autism”. Interestingly this group of children had a far higher number of girls.

Symptoms of Pathological Demand Avoidance (PDA)

The most obvious feature is an obsessional avoidance of the ordinary demands of life coupled with a degree of sociability that allowed social manipulation as a major skill. Despite  reluctance to use the word “manipulative” in speaking of children, it’s impossible not to recognise this shared quality, especially as it is the opposite of autistic children.

Why Pathological Demand Avoidance requires a different diagnosis from Autism

An important reason for needing the separate diagnostic term is due to the different needs of the child with PDA. Specialist schools for “autistic” children, which include one or two with PDA, immediately discover the enormous difficulties posed by a child who is deeply threatened by educational demands and organisational rules.

The guidelines that are successful with autistic children need major adaptations for PDA children if any progress is to be made; these children hate routine and thrive best on novelty and variety. If perceived as ASD children, the wrong advice will be given: PDA children suffer a high exclusion rate if educated on autistic guidelines, as do young adults.

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Pathological Demand Avoidance (PDA) is increasingly, but not universally, accepted as a profile that is seen in some autistic people. PDA is also known as Extreme Demand Avoidance as some feel extreme is a more acceptable term than pathological.

Features of a PDA profile

The symptoms of Autism can vary considerably depending on the combination of a person’s strengths and difficulties across two key dimensions:

  • how someone relates socially
  • the need for sameness, often resulting in repetitive or rigid thoughts and behaviours.

People with a PDA profile can appear to have better social understanding and communication skills than some other autistic people, and are often able to use this to their advantage. However, these apparent social abilities can often mask difficulty with processing and understanding communication and social situations.

The distinctive features of a demand avoidant profile include:

  • resists and avoids the ordinary demands of life
  • uses social strategies as part of avoidance, for example, distracting, giving excuses
  • appears sociable, but lacks some understanding
  • experiences excessive mood swings and impulsivity
  • appears comfortable in role play and pretense
  • displays obsessive behaviour that is often focused on other people.

People with this profile can appear excessively controlling and dominating, especially when they feel anxious. However, they can also be confident and engaging when they feel secure and in control. It’s important to acknowledge that these people have a hidden disability.

People with a PDA profile are likely to need a lot of support. The earlier the recognition of PDA, the sooner appropriate support can be put in place.

Treatment for Extreme Demand Avoidance

There is no cure for PDA. Treatment interventions can be difficult as the nature of the disorder means that the individual is obsessively concerned with avoiding any demands placed upon them, including treatment methods. Wording of demands is important; they must be indirect in nature and are often more effective if they are short and not confusing.

Therapists working with individuals with PDA are prepared for avoidance tactics and strategies to overcome avoidance demands. It is important that individuals are provided with plenty of time to enable them to process information. If an individual with PDA performs a task correctly they should be praised to emphasise their personal qualities, failure should not be recognised as this will reinforce this behaviour. Assessments will be used to identify problems or difficulties in the following areas:

  • Communication skills – expressive and receptive language
  • Social skills
  • Sensory processing
  • Motor skills – gross and fine
  • Learning ability

PDA can be treated by a number of professionals within a multi-therapy approach. Professionals who are often involved in the assessment and treatment of individuals with PDA include:

  • Speech and language therapists
  • Physiotherapists
  • Occupational therapists

For most individuals with Pathological Demand Avoidance, there is a great need for their educational needs to be met. It is vital for these individuals to have 1:1 support normally through a teaching assistant or key worker.

Educational needs for an individual with Pathological Demand Avoidance can be summarised under three main areas:

  • Keeping the child on task for substantial periods throughout the school day
  • Ensuring that what they appear to be learning they are actually absorbing and retaining – many children with this disorder will appear to be learning but may not be processing or absorbing the information. This may occur when the child feels that fewer demands will be made of them if they appear to be attentive
  • Ensuring that there is a minimal degree of disruption to other children – not all children with Pathological Demand Avoidance are disruptive, however, this may occur if they are trying to resist social demands

Whatever the child’s intellectual ability they will function at a level below what they could achieve due to the fact they will be active in being passive, often working harder to avoid the demand than they would have done if they had accepted it. It is therefore important that educational support is aimed at helping the child tolerate being educated to allow them to reach as much of their potential as possible.

Support required for children with Pathological Demand Avoidance is extensive. It is important that professionals and parents/carers know that what works on one day may not be effective the following day due to the highly variable nature of this disorder.

Health professionals can provide valuable help and strategies for parents/carers of children with Pathological Demand Avoidance enabling them to deal with situations that may arise within a home setting and helping them to meet the child’s continuing needs whilst maintaining a happy home environment for everyone.

If you require an assessment, you could contact The ASD Clinic:  by emailing office@asdclinic.co.uk or calling 0330 088 6693.

For more info: https://www.asdclinic.co.uk/index.php

 

Featured image: Photo by Dmitry Schemelev on Unsplash