Where did Pathological Demand Avoidance (PDA) originate and why doesn't the Diagnostic and Statistical Manual of Mental Disorders (DSM) recognize it?

The Origin and Recognition Status of Pathological Demand Avoidance (PDA)

Pathological Demand Avoidance (PDA) originated in the United Kingdom in the 1980s when Elizabeth Newson coined the term to describe children who obsessively resist everyday demands, but it is not recognized in major diagnostic classification systems like the DSM because there is insufficient evidence to support it as a distinct syndrome.

Origin of Pathological Demand Avoidance

• PDA was first described by Elizabeth Newson in the 1980s in the United Kingdom to characterize children who show extreme avoidance of everyday demands and instructions 1, 2
• The term was created to describe children who display obsessive resistance to demands, going to extreme lengths to avoid complying with requests 1
• Unlike typical autism spectrum presentations, children described as having PDA reportedly use socially manipulative avoidance strategies and show an obsessive need for control 2

Key Features of the PDA Profile

• PDA is characterized by extreme avoidance of demands that are perceived as threatening or anxiety-provoking 3
• Features include apparently strategic use of distraction, socially shocking behavior, and domineering control over peers and adults 2
• Children with PDA traits often show sudden behavioral changes from loving to aggressive, and display anxiety when faced with demands 2
• The Extreme Demand Avoidance Questionnaire (EDA-Q) was developed as a parent-report measure to quantify PDA traits, showing good sensitivity and specificity in preliminary validation 1

Why PDA Is Not Recognized in the DSM

• PDA is not included in major classification systems like the DSM-5 or ICD-10 as a distinct disorder or as a subtype of autism spectrum disorder 4, 5
• Current evidence does not support the validity of PDA as an independent syndrome, despite its increasing clinical use 5
• The behaviors associated with PDA can be understood through existing diagnostic frameworks within the DSM, including:
  • Features of autism spectrum disorder with co-occurring anxiety 4
  • Disruptive behavior disorders or conduct problems 4
  • Obsessive-compulsive related disorders 6

Current Understanding of PDA Behaviors

• Research suggests that intolerance of uncertainty (IU) and anxiety may explain the demand avoidant behaviors seen in children described as having PDA 3
• Demand avoidant behavior may represent attempts to increase certainty and predictability to alleviate anxiety 3
• Children with PDA features employ various strategies to manage uncertainty depending on the level of demand and anxiety generated, including control behaviors, withdrawal to fantasy, and meltdowns 3

Clinical and Research Implications

• The use of PDA as a diagnostic label has led to altered referral practices and misunderstandings between professionals and families 5
• Understanding the underlying mechanisms of demand avoidance (such as cognitive rigidity and intolerance of uncertainty) is more clinically useful than applying an additional label 4
• Management approaches reportedly effective for PDA differ from typical autism interventions and include novelty, humor, and flexibility 2
• Identification of PDA features in individuals with autism may have important implications for educational and behavioral management strategies 2

Current Research Status

• Research on PDA is still in early stages, with most studies focusing on developing measurement tools and understanding behavioral profiles 1, 2
• The Diagnostic Interview for Social and Communication Disorders (DISCO) has been used to identify items relevant to PDA, bringing the field closer to a clinician-rated measure 2
• Further research is needed to elucidate whether PDA represents a distinct profile or is better understood as a constellation of features within existing diagnostic categories 5