Does your child have Pathological Demand Avoidance (PDA)? Here’s the good news – it’s “treatable”!

Jenna had reached out to me because her 9-year-old son was out of control at home and at school; he was violent; and he was sent home from school so often, Jenna was about to lose her job. Her son had been diagnosed with ADHD and autism, and his psychiatrist had told her that his behavior couldn’t change: “Face it,” he said. “Your child has a mental illness. You are NOT going to be able to work full-time. This is your life now.”

Jenna’s son did change, though. With my help Jenna was able to reduce her son’s explosive meltdowns AND the physical aggression by 85%; by the end of our time (8 weeks) together he was doing well in school and attending full time – and Jenna was offered a promotion at work!

And in the last 15 minutes of our last meeting, Jenna asked what to me was an interesting question: “So did he have PDA?” Jenna had been researching PDA (Pathological Demand Avoidance) and had seen that her son’s behavior had met all of the “criteria” she had read about. “I was able to check off ALL the boxes before I started working with you,” she said. “He fit the pattern, but I’ve read that PDA is a lifelong condition [e.g., see pdasociety.org.uk]. But now he’s SO much better. So did he have PDA?

Because Jenna’s son had been highly demand-avoidant and because PDA is simply a behavioral profile (it’s not a recognized medical condition), I could have answered, “Yes, of course he did!” You’ll see what I think about that as you read this blog. First, let’s define PDA!

What is Pathological Demand Avoidance (PDA)?

Pathological Demand Avoidance (PDA) is just what it sounds like: A behavioral profile characterized by significant (“pathological”) resistance to everyday demands and expectations.

As the Child Mind Institute describes PDA in children, while “all kids avoid doing things they’re asked to do from time to time,” kids fitting the PDA profile “go to extremes to … resist anything they perceive as a demand.” Quite often this resistance takes the form of a tantrum or violent meltdown; and kids who fit the pattern are often physically aggressive. And as the term suggests, the central theme in PDA is “parents’ (or teachers’) directives”: Kids with this profile refuse to listen not because they can’t DO what the grownup is asking; instead, they don’t listen because the grownup is asking, period. Experts note that kids “with PDA” resist directives even when listening would benefit them; and as one might expect, their resistance is considered “pathological” because it interferes with functioning at home or at school.

Does all this sound familiar? I’ll never forget the 8-year-old who told me, “If my mom asks me to do something, I have to NOT do it. I have to NOT do what she asks me to do.” I focus my parent coaching practice on strong-willed kids and kids who struggle with emotional dysregulation – and almost all of the parents in my coaching programs have a child or two whose behavior matches the PDA pattern!

But what IS PDA??

PDA advocates typically view PDA as “a profile of autism” and PDA is generally assumed to be based in fear: Dr. Cynthia Martin, a clinical director at the Child Mind Institute, tells us that though PDA is sometimes “mistaken” for willful defiance, “it’s better understood as a result of anxiety and inflexibility”: Like the child with autism spectrum disorder (ASD), the child “with PDA” is thought to be both less adaptable and less attuned to social communication. In turn, to the child who fits the profile, grownups’ demands seem to “come out of nowhere,” and this might be distressing.

There’s also some speculation that kids with PDA may experience social deficits that make it hard for them to understand that the parent or teacher should be listened to; and many if not most advocates assert that Pathological Demand Avoidance derives from an anxiety-driven need for control.

Is Pathological Demand Avoidance “real”?

As described above, PDA advocates view PDA as medically-based – and as a profile of ASD, PDA would be considered a neurological and developmental psychiatric disorder.

On the other hand, according to the UK’s National Autistic Society, though demand avoidance “is widely acknowledged as a characteristic reported by and observed in some people,” there is “very little research into [PDA]”; “no research has found strong evidence for the group of traits proposed for PDA”; and the research that does exist is “generally of a low quality.”

Neither the US nor Canada nor the UK recognizes PDA as a psychiatric condition, and not every advocate thinks it’s autism: Some believe PDA should be its own “neurological difference”; others believe PDA may be linked to conditions other than ASD (for example, ADHD or ODD); and Dr. Martin acknowledges that PDA can occur in the “broader population.”

Notably, Dr. Martin also reports that parents of kids who DON’T have ASD are increasingly asking whether their child might still have PDA. And this is remarkably consistent with my own professional experience. I’ve worked with thousands of families over the years. And while I do work with parents of kids on the Spectrum, most of the parents I work with DON’T have kids on the Spectrum; yet as I mentioned above, almost all of the parents in my coaching programs have a child whose behavior fits the PDA profile!

The medicalization of problem behaviors is trending these days. Nowadays it’s all too easy to frame behaviors such as demand avoidance and the tantrums and meltdowns that go with it as medical constructs – and this is SO unfortunate, because when we do that, we overlook two critical factors that better explain all behavior: temperament and learning. And these factors are key whether or not the “pathology” is actually present. In other words, even if the problem behavior DOES have a medical component, it’s a mistake to reduce the behavior to the diagnosis. Sure, pathology may play some part in the behavior, but temperament and learning play a greater role.

It’s a bird! It’s a plane! Could it be… Temperament???

Temperament, as I’m sure you know, is a component of personality. Temperament is a key driver of one’s reactions to life situations and life experiences; it “arises” or appears in early infancy; it’s more stable or “lifelong” than other aspects of personality; and it’s determined in large part by genetic factors. (For example, see J. Strelau’s chapter,“Temperament,” in the Encyclopedia of Personality and Individual Differences).

And when we consider temperament frameworks such as that proposed by temperament pioneers Stella Chase, Alexander Thomas and James Cameron (e.g., see preventiveoz.org), we can see that kids who are highly demand-avoidant tend to fall on either the high or the low end of the spectrum on specific temperament traits. Chase et al. describe temperament as consisting of 9 distinct traits, including:

  • Sensitivity (e.g., to stimuli such as sound or touch);
  • Distractibility;
  • Movement (i.e., the person’s activity level or energy level);
  • Emotional intensity/emotional reactivity;
  • Adaptability;
  • Approach (i.e., the readiness with which the person approaches unfamiliar people or unfamiliar situations);
  • Frustration tolerance;
  • Regularity (i.e., the degree to which the person eats or sleeps at consistent times); and
  • Soothability (i.e., the person’s responsivity to soothing or calming stimuli)

And in the course of a twenty-five-year career in which I’ve worked extensively with demand-avoidant kids, I’ve observed that these kids are almost always 1) high in sensory sensitivity; 2) high in emotional intensity; 3) high in emotional reactivity; 4) much less adaptable; 5) low in frustration tolerance; and 6) much less soothable. In other words, demand-avoidant kids share a number of temperament traits – they have a similar temperament profile. And as it turns out, most of the traits within this profile map directly to another personality trait – our orientation toward control.

Pathological Demand Avoidance: It’s all about CONTROL!

While the kids I meet in my coaching practice are almost always highly demand-avoidant, I don’t frame their behavior as such. Instead, I use the term “strong-willed” – and like the PDA advocates, I attribute their behavior to a need for control! Demand-avoidant kids do have a high need for control. But it isn’t based in anxiety; instead, it’s based in temperament.

More specifically, while “need for control” is not typically viewed as a temperament trait per se, again, it is an aspect of personality; and there are a number of temperament traits that map directly to control. Take adaptability, for example, or low frustration tolerance. It’s easy to see how a child with a high need for control would almost always be less adaptable and more easily frustrated! And of course the child who’s easily frustrated also gets frustrated more often. And you can see how ongoing or “chronic” frustration would increase the child’s vulnerability to emotional distress, such that they’re more “reactive”!

Kids with a high need for control are high in emotional reactivity, and they DO get anxious when they experience a lack of control. But getting anxious because you don’t have what you need is different from needing what you need because you’re anxious. Research in psychology has firmly established control as key to mental health, and it’s reasonable to assume that kids who are temperamentally predisposed to be, say, highly sensitive and less adaptable, may feel they need more control!

Pathological Demand Avoidance: Nature (temperament) AND nurture (learning!)

Of course, this can be hard on grownups. It can be hard for parents to meet a demand-avoidant child’s need for control without “compromising” their own control, because in the beginning kids with a high need for control tend to think they need ALL the control – and when they don’t have the control they want, the meltdowns can be extreme.

But this is where learning – and teaching – come in.

In other words, just due to where they are in the course of human development, kids are inherently concerned primarily with their own experience – and their own goals. It’s only natural that a child would just go for what they want, and if control is what they want, why would they give that up?? Kids have to LEARN to do the things they don’t want to do – they aren’t born with this self-regulation skill. And kids with a high need for control have to learn to listen, and cooperate.

And it’s the grownups who have to teach them, of course. But when you reduce a behavior to medical causes and you ignore the role of learning, kids CAN’T learn –because grownups are told these kids can’t be taught. Remember Jenna, who had heard that demand avoidance is a lifelong “condition”? The implication is obvious: We wouldn’t expect the child with “pathological” demand avoidance to maintain that behavior throughout the course of their life unless we thought they just couldn’t change!

The presumption that kids “with PDA” can’t be taught to listen is also apparent in the recommended “interventions” for demand avoidance. Take, for example, the suggestion that we “reframe” the problem behavior as something the kids just can’t control. And consider the (UK) National Autistic Society’s number-one recommendation: “reducing and/or removing demands.” Don’t take it personally, the advocates tell us. These kids aren’t defiant; they’re just scared, and they can’t help it! And they won’t avoid demands if there are no demands to avoid!

I’ll talk more about PDA interventions in another blog. For now, suffice it to say that it’s not really fair to categorize reframing or removing demands as interventions or treatment approaches, since these do nothing to change the child’s behavior.

And demand-avoidant kids CAN change. I see it every day. Even in kids with ASD, or ADHD, or ODD – the predominant “cause” of behavior is learning. And demand-avoidant kids can learn, and they can change, and they can be taught to cooperate and compromise. Remember Jenna’s son, the boy I told you about above? With his mom’s and my help he made some dramatic changes in just 8 weeks. And he had an ASD diagnosis!

PDA take-aways:

  • Pathological Demand Avoidance (PDA) is generally assumed to be linked to ASD, but this assumption is not based in research. Neither the US nor Canada nor the UK recognizes PDA as a psychiatric condition.
  • Parents of kids who DON’T have ASD are increasingly asking whether their child might still have PDA. Most of the parents in my coaching programs have a child or two whose behavior fits the PDA profile.
  • “Pathological” demand avoidance is better explained by temperament and learning.
  • The primacy of learning is a major tenet of psychology: Learning is the mechanism by which we acquire new behaviors, and learning is the primary factor in behavior change. (Note that learning is not the same as “knowing.” A child may know how to perform a behavior without having learned to do so consistently.)
  • Kids “with PDA” are able to learn. Kids with PDA can learn how to have the control they need in ways that work for everyone. They can learn to cooperate and they can learn to self-regulate. While kids who are temperamentally predisposed to have a high need for control will always have a high need for control, demand avoidance is entirely reversible. I see this every day, not only in kids without psychiatric diagnoses, but also in kids with ASD, ADHD, and ODD.
  • We can absolutely meet the high need for control so often displayed by kids “with PDA” without lowering our expectations for their behavior. In fact, demand-avoidant kids do much better when parents and teachers maintain high standards for behavior. This is something else I see in my coaching practice.

Demand-avoidant kids are strong-willed, and a strong-willed person is a powerful person. But it’s up to us to teach them to use their power in ways that work for everyone. That’s not always easy – and that “lesson” can take a minute. But when you teach a demand-avoidant, strong-willed child to work with you instead of against you, both you AND they are so much happier, and your time together is so much more productive!

Would you like my help?

Does YOUR child fit the PDA profile? If they do, I can teach you how to teach them to listen and self-regulate. Go here to schedule a free consult with me!

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