Extreme/‘pathological’ demand avoidance: an overview

Abstract Pathological demand avoidance (PDA) was coined in the 1980s to describe children on the spectrum of pervasive developmental disorders who show an obsessive resistance to everyday demands, an extreme need for control, and an apparently poor sense of social identity, pride, or shame. The term PDA has since attracted considerable interest and controversy. Here, we provide an overview of PDA, discuss the clinical presentation of individuals with a PDA profile, and differences compared to children with documented attachment difficulties. We then discuss empirical work describing how anxiety-driven avoidance of routine demands can emerge in children with ASD. We provide recommendations for strategies that aim to avoid strengthening habitual avoidance behaviours, and instead, allow new mutually rewarding routines to develop, which may provide opportunities to gradually increase the child's tolerance of demands. We argue that using the PDA profile, or describing relevant behaviours, as part of a clinical formulation can be helpful in alerting caregivers and educational professionals to particular challenges surrounding compliance with everyday requests in some children with ASD.