What Does Pathological Demand Avoidance Look Like in Adults?

Pathological demand avoidance (PDA) is a tendency for autistic individuals to struggle when overwhelmed by demands. On the outside, it can look like defiance or choosing not to do necessary things. On the inside, it can feel like a mind storm.

Validity of Pathological Demand Avoidance

When I first came across the term PDA, admittedly on social media, my first reaction was skepticism. Who doesn't avoid doing things they don't want to do? The initial "pathological" gave me a sense that this could be rebranding oppositional defiant disorder, another construct I have found problematic.

Yet, as I took time to look into the history of the idea, my perspective opened.

PDA was first identified in 1983. The phenomenon was proposed as a subtype of autism wherein individuals demonstrate a significant need for control to manage anxiety due to the overwhelm that thrives through the autistic processing style (Newson et al., 2003). While not listed as a separate diagnosis within the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), many researchers and clinicians accept PDA as a profile of autism. The diagnosis is more recognized in the United Kingdom than in the United States.

For children, PDA is characterized by saying "no" to demands, even to things the child would want to do, and difficulty doing things when asked (as opposed to on their own accord). There appears to be a need to direct one's schedule and surroundings. Youth with PDA might not honor the traditional social hierarchy between adults and children and may inadvertently come across as "bossy." Still, these actions are a means of self-preservation, not of misbehavior.

Behavioral interventions like rewards or punishments are generally not recommended in approaching this challenge as these can backfire as the individual feels even more alone and out of control (O'Nions and Eaton, 2020). Instead, carefully planned interventions reduce stress/demands and improve collaboration.

Advocates often refer to PDA as a "persistent drive for autonomy (PDA)," emphasizing the need for independence rather than avoidance behavior. The construct of PDA continues to hold a degree of controversy and is a subject of investigation.

PDA in Adults

Although PDA has been studied primarily in children, it can also affect adults. A study that adapted the Extreme Demand Avoidance Questionnaire for adults found that autistic adults with a PDA profile had higher levels of disagreeableness and emotional instability. They also showed higher scores on the Autism Screening Questionnaire (Egan et al., 2019).

One way that PDA may be especially prevalent in autistic adults is with procrastination. Here, individuals may find themselves overwhelmed with where to start on a project or with a list of tasks to the point of being unable to concentrate. Research has shown that anxiety and intolerance of uncertainty correlate with PDA in adults (Johnson et al., 2023).

Executive functioning challenges further this phenomenon.

The autistic processing style, wherein details are not filtered out, creates an intense world priming one for overwhelm (Markram and Markram, 2010).

PDA also often affects adult relationships. A person might have an extra need for control when plans are drawn and in other regards. If others do not understand, it can be tricky.

Support

What follows are three strategies for flourishing with PDA.

1. Reduce overwhelm. When overwhelmed, individuals with a PDA profile are likely to freeze, making procrastination and interpersonal conflict more likely. Taking count of one's stresses is critical to the well-being of individuals with a PDA profile. Reducing stress might look different for everyone. Still, some common steps include integrating a routine, having regularly scheduled free time, and decreasing sensory demands.
2. Increase sense of autonomy/control. Feeling out of control is a trigger for PDA. It is also not healthy or realistic to be in control of every situation. Nonetheless, taking agency in a few spaces that matter is likely to improve one's sense of autonomy. For example, one person might have a corner or room that is their dedicated space to curate and access when stressed.
3. Seek understanding before judgment. Support and understanding from others are key to being at one's best. This holds for people with a PDA profile. Psychoeducation on PDA and open minds from others are key here. This is not to say that all others should bend to the will of the person with a PDA profile. Still, understanding the purpose behind the tendencies can foster more helpful responses from one's environment.