Pathological demand avoidance

Pathological demand avoidance (PDA) is a proposed disorder and sub-type of autism spectrum disorder,[1] defined by characteristics such as a greater refusal to follow the requests of others.[1] Although PDA has its own traits that are separate from autism, they generally meet the diagnostic criteria by having significant difficulties in social interaction and communication.[1] Alternatively, they may instead be diagnosed with ODD.[1] Those who propose PDA should be a separate diagnosis from classic autism spectrum disorders observed children with PDA to be more sociable, have better social skills and social understanding, use apparently socially manipulative and shocking behaviour,[2][3] to tend to be more interested in people than objects, to be more comfortable with pretend play, and to tend to be more imaginative. PDA is not recognised by either the DSM-5[4] or the ICD-10.[5] The term was proposed in 1980 by the UK child psychologist Elizabeth Ann Newson.[3][6] PDA is observed in adults as well.[7]


Pathological demand avoidance is not recognized by the DSM-5 or ICD-10, the two main classification systems for mental disorders.[8] 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, DSM-5 also moved from sub-type classification to the use of ‘Autistic Spectrum Disorder’, which allows for the behavioural traits of different profiles to be described.

In 2011, the National Institute for Health and Care Excellence commented on the fact that PDA has been proposed as part of the autism spectrum but did not include further discussion within the guideline.[1] 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).[1]

Christopher Gillberg wrote a commentary article in 2014 that reviewed recent research and stated, “Experienced clinicians throughout child psychiatry, child neurology and paediatrics testify to its existence and the very major problems encountered when it comes to intervention and treatment.”[9]

Diagnostic criteriaEdit

As of 2014 there are no recognised diagnostic criteria.[8] Observations in children with PDA that were identified as common features[2] that potential possible diagnostic criteria could be based on include:

  1. Passive early history in the first year, avoiding ordinary demands and missing milestones
  2. Continuing to avoid demands, panic attacks if demands are escalated
  3. Surface sociability, but apparent lack of sense of social identity
  4. Lability of mood and impulsivity
  5. Comfortable in role play and pretending
  6. Language delay, seemingly the result of passivity, often caught up quickly
  7. Obsessive behaviour
  8. Use of apparently socially manipulative and shocking behaviour[2]
  9. Neurological signs (awkwardness, similar to autism spectrum disorders[10])

Causes of demand avoidanceEdit

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 generalised anxiety disorder or another anxiety disorder may be made instead of PDA.[11] About 40% of autistic people suffer from an anxiety disorder.[12]

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.[13]

Naming controversyEdit

'Pathological demand avoidance' has been criticized as a name for various reasons including the negative connotations some confronted with the word 'pathological' might have,[14] and alternative names like RDA for 'Rational Demand Avoidance'[15][16] or 'Pervasive Drive for Autonomy'[17][18] have been proposed and used.


Newson first began to look at PDA as a specific syndrome in the 1980s when certain children referred to the Child Development Clinic at the University of Nottingham appeared to display and share many of the same characteristics. These children had often been referred because they seemed to show many autistic traits, but were not typical in their presentation like those with classical autism or Asperger's syndrome. They had often been labelled as 'atypical autism' or Persistent Development Disorder-Not Otherwise Specified (PDD-NOS). Both of these terms were felt by parents to be unhelpful.[citation needed]

When Newson was made professor of developmental psychology at the University of Nottingham in 1994, she dedicated her inaugural lecture to talking about pathological demand avoidance syndrome.[19]

In 1997, the PDA Society was established in the UK by parents of children with a PDA profile of autism. It became a registered charity in January 2016.[20]

In July 2003, Newson published in Archives of Disease in Childhood for PDA to be recognised as a separate syndrome within the pervasive developmental disorders.[3]

In 2020, an Incorporated Association was established in Australia. 'Pathological Demand Avoidance Australia Inc.' became a registered charity early 2021.[21]

A systematic review published in 2021 by Kildahl et al [22] found that many of the studies published on PDA had methodological limitations, which restricted conclusions that could be drawn about patterns of behaviours characteristic of PDA. The authors noted that "currently, we still lack adequate information regarding the uniformity of demand avoidant behaviours, across individuals or over time."

Social psychologists Damian Milton and Devon Price have suggested the behaviour should not be considered pathological, and contextualise PDA as an example of individual autonomy or self-advocacy.[23]


  1. ^ a b c d e f National Collaborating Centre for Women’s and Children’s Health (September 2011). Autism: recognition, referral and diagnosis of children and young people on the autism spectrum (PDF). pp. 235, 286. PMID 22624178.
  2. ^ a b c O'Nions E, Gould J, Christie P, Gillberg C, Viding E, Happé F (April 2016). "Identifying features of 'pathological demand avoidance' using the Diagnostic Interview for Social and Communication Disorders (DISCO)". European Child & Adolescent Psychiatry. 25 (4): 407–419. doi:10.1007/s00787-015-0740-2. PMC 4820467. PMID 26224583.
  3. ^ a b c Newson E, Le Maréchal K, David C (July 2003). "Pathological demand avoidance syndrome: a necessary distinction within the pervasive developmental disorders". Archives of Disease in Childhood. Royal College of Paediatrics and Child Health. 88 (7): 595–600. doi:10.1136/adc.88.7.595. PMC 1763174. PMID 12818906.
  4. ^ American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
  5. ^ "ICD-10 Version:2016". Retrieved 22 January 2018.
  6. ^ Feinstein A (2010). A History of Autism: Conversations with the Pioneers. Wiley-Blackwell. p. 181. ISBN 978-1-4051-8654-4.
  7. ^ "Pathological Demand Avoidance: an adults perspective".
  8. ^ a b Department of the Official Report (Hansard), House of Commons Westminster. "House of Commons Hansard Written Answers for 28 Apr 2014 (pt 0002)".
  9. ^ Gillberg C (July 2014). "Commentary: PDA--public display of affection or pathological demand avoidance?--reflections on O'Nions et al. (2014)". Journal of Child Psychology and Psychiatry, and Allied Disciplines. 55 (7): 769–770. doi:10.1111/jcpp.12275. PMID 24890260.
  10. ^ "Part of the Autism Spectrum". PDA Society.
  11. ^ Stuart L, Grahame V, Honey E, Freeston M (May 2020). "Intolerance of uncertainty and anxiety as explanatory frameworks for extreme demand avoidance in children and adolescents". Child and Adolescent Mental Health. 25 (2): 59–67. doi:10.1111/camh.12336. PMID 32307839. S2CID 182321645.
  12. ^ Zaboski BA, Storch EA (February 2018). "Comorbid autism spectrum disorder and anxiety disorders: a brief review". Future Neurology. 13 (1): 31–37. doi:10.2217/fnl-2017-0030. PMC 5772195. PMID 29379397.
  13. ^ Dundon R (21 November 2019). The Parents' Guide to Managing Anxiety in Children with Autism. Jessica Kingsley Publishers. p. 114. ISBN 9781785926570.
  14. ^ "Autistic PDA: Persistent Drive For Autonomy, by Jillian Enright / neurodiversified".
  15. ^ "(PDF) "Pathological"/ "Extreme"/ "Rational" Demand-Avoidance: Reviewing and Refining its Contested Terrain Through an Educational Perspective. - A Frontiers in Education PDA special issue".
  16. ^ "Rational (Pathological) Demand Avoidance / 7 / As a mental disorder an".
  17. ^ "Reframing PDA: The power of an Autistic perspective - Reframing Autism".
  18. ^ "PDA Day-to-Day: Parenting Pathological Demand Avoidance/ Pervasive Demand for Autonomy / Neurodiverging".
  19. ^ Christie P (February 20, 2014). "Elizabeth Newson obituary". The Guardian. Retrieved December 13, 2020.
  20. ^ "About the PDA Society". PDA Society. Retrieved December 13, 2020.
  21. ^ "PDA Australia". PDA Australia. Retrieved June 17, 2021.
  22. ^ Kildahl AN, Helverschou SB, Rysstad AL, Wigaard E, Hellerud JM, Ludvigsen LB, Howlin P (November 2021). "Pathological demand avoidance in children and adolescents: A systematic review". Autism. 25 (8): 2162–2176. doi:10.1177/13623613211034382. hdl:10072/406678. PMID 34320869. S2CID 236498146.
  23. ^ Hess P (August 11, 2022). "Pathological demand avoidance in autism, explained". Spectrum. doi:10.53053/YKGQ6660. S2CID 251477348. Retrieved March 2, 2023.

Further readingEdit