By Ms Sarah Ormond, Psychologist
Pathological (extreme) demand avoidance (PDA) is a term applied to patterns of complex behaviours that may be seen in some children on the autism spectrum, who often experience heightened anxiety. Children with demand avoidance may present with difficulties in social communication, social interaction, relationships, and may present with obsessive and rigid behaviour consistent with ASD; however, PDA is proposed to be unique in that the children avoid demands placed upon them to an extreme level, resisting and avoiding the ordinary demands of everyday life (Newson, Maréchal & David, 2003). Examples of these avoidance behaviours may include refusing or ignoring requests, behaving in socially inappropriate ways, being aggressive, emotional outbursts (tantrums), and hurting themselves or others (Newson et al. 2003).
Increased social media presence and diagnosis by psychiatrists has led to calls for PDA to be used as an independent diagnosis from ASD, despite not being included in the DSM-V. This is up for much debate and discussion. It could be the case that the difficulties that children proposed to be identified as having PDA can be explained through understanding the social, sensory and cognitive sensitivities that are present in ASD (Green et al. 2018). Additionally, frequently occurring comorbid disorders and the child’s social environments can potentially account for some of the variations in behaviour that present as PDA (Giltaij et al., 2015; Sadiq et al. 2012). For example, an anxious child may seek to control a social environment and situations as a way of ameliorating the discomfort that comes with anxiety. Many aspects of everyday living for children with ASD are anxiety provoking and promote unpleasant feelings. It should be recognised that the strategies and behaviours that children employ to avoid these feelings can be attempts to defend against and mechanisms to reduce their anxiety. Situations that are anxiety provoking for children with ASD include the expectations of others, processing information, confusion in social situations and interpreting the emotions of others, sensory overload and tolerance of emotions.
It is true that accurate diagnosis may lead to more effective treatment. However, as it stands currently for children presenting with symptoms of PDA, there is more benefit to the focus on the individual management strategies for children, families, therapists, and teachers that can be used to guide and encourage alternative and positive behaviours (Green et al. 2018).
5 Strategies to guide and encourage positive behaviours for parents and teachers:
1. Look below the surface of the iceberg – what are the feelings that could be making your child feel anxious? Difficult behaviours that are being presented will often be in response to the rising anxiety in your child. Look for the triggers and difficulties that could be encouraging the behaviour in the first place.
2. Try not to take your child’s behaviours personally – even if they are hurtful. Your child’s attempts to mitigate their anxiety may be a better explanation than blaming your parenting or teaching skills.
Boundaries and demands
3. Choose non-negotiable boundaries and provide clear reasons for doing so – your child may be more likely to understand if they know why it is important.
4. Use indirect demands that can be seen as fun and challenging – combine tasks, humour, and play to encourage involvement with them, point out when they are doing things that are valuable to you, and even pretend that you do not know certain things and ask them to explain it to you – this may help increase their emotional wellbeing and sense of autonomy.
5. Offer limited choices – give two options, i.e. “Would you like to go the park at 2:00pm or 3:00pm?” Be prepared to negotiate with them i.e. “Okay, if you want to go at 2:30 pm, we can go then”. Allowing them expression of choice may increase their sense of autonomy and increase positive outcomes for all. Sometimes giving too much choice can lead to a rise in anxiety.
6. Stay calm and neutral in your verbal and non-verbal communication (easier said than done, though a worthy aspirant) – allowing your stress or anger to impact your responses and behaviour may increase your child’s anxiety, and therefore decrease their tolerance for demands.
7. Use roleplays and other forms of indirect communication. Use their toys to suggest ideas i.e. “Buzz Lightyear has asked if we have dinner at 6:00 pm?”. With older children, you could try text messaging or leaving notes around the house.
For more information and strategies, please see the below links and references.
Giltaij, H.P., Sterkenburg, P.S. & Schuengel, C. (2015). Psychiatric diagnostic screening of social maladaptive behaviour in children with mild intellectual disability: differentiating disordered attachment and pervasive developmental disorder. Journal of Intellectual Disability Research, 59(2), 138–149.
Green, J., Absoud, M., Grahame, V., Malik, O., Simonoff, E., Couteur, A., & Baird, G. (2018). Pathological Demand Avoidance: symptoms but not a syndrome. The Lancet: Child & Adolescent Health, 2 (6), 455-464.
Newson E, Le Maréchal K, David C. (2003). Pathological demand avoidance syndrome: a necessary distinction within the pervasive developmental disorders. Archives of Disease in Childhood. 88, 595-600.
O’Nions, E., Gould, J., Christie, P., Gillberg, C., Viding, E., & Happé, F. (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
Sadiq, F.A., Slator, L., Skuse, D. et al. (2012). Social use of language in children with reactive attachment disorder and autism spectrum disorders. European Child and Adolescent Psychiatry, 21, 267–276.