Pathological Demand Avoidance: What Mental Health Professionals Need to Know
In recent years, more parents and caregivers have begun asking about Pathological Demand Avoidance (PDA). Some families feel the term finally explains their child’s intense reactions to everyday expectations, while others encounter confusion due to conflicting information and strong opinions surrounding the label.
For mental health professionals, PDA can be challenging. It appears frequently in parent conversations and online communities, yet remains controversial within clinical and research settings. A 2021 systematic review by Kildahl and colleagues helps clarify what we currently know—and what remains uncertain—about PDA in children and adolescents.
What Is Pathological Demand Avoidance?
PDA was originally described as a pattern of extreme avoidance of everyday demands. These children may strongly resist requests, become distressed when they feel controlled, and show sudden emotional escalations when expectations are placed on them.
Although these behaviors may appear oppositional, families often describe them as fear-based rather than intentional defiance. Avoidance can be intense, unpredictable, and emotionally charged, often leaving caregivers and professionals feeling unsure how to respond.
Over time, PDA has been described in different ways: as a distinct diagnosis, a profile within autism, or simply a cluster of behaviors. This lack of agreement is one reason the concept remains so debated.
Why Is PDA Controversial?
A major concern is that the term “pathological demand avoidance” focuses on behavior without fully explaining why the behavior occurs.
Autistic researchers and advocates have raised important questions, including whether these behaviors are better understood as responses to anxiety, stress, or loss of perceived control. From this perspective, avoidance may represent an attempt to cope with overwhelming situations rather than deliberate noncompliance.
These concerns shaped the focus of the 2021 systematic review.
What Did the Review Examine?
Kildahl and colleagues reviewed 13 peer-reviewed studies on PDA in children and adolescents. Most were conducted in the United Kingdom and used a wide range of research methods.
Rather than determining whether PDA “exists,” the authors focused on evaluating the quality of the research, how PDA has been identified, and what is known about its relationship to autism and mental health.
Key Findings
1. The Research Base Is Limited
All studies reviewed had significant limitations. Many included small samples, unclear definitions, and inconsistent criteria for identifying PDA. Because of this, the authors concluded that current evidence is insufficient to define PDA as a stable or distinct diagnosis.
Importantly, this does not mean the children’s difficulties are not real—it means the research has not yet provided clear answers about how best to conceptualize them.
2. PDA Is Identified in Many Different Ways
There is no standardized method for identifying PDA. Most studies relied on parent questionnaires or autism interviews that were not designed specifically to assess demand avoidance.
Different studies used different criteria, even when referencing the same concept. This makes it difficult to know whether researchers are examining the same phenomenon across studies.
3. Most Information Comes from Parents
Nearly all studies relied almost entirely on parental report. No studies included direct self-report from children or adolescents themselves.
This gap is significant. Without hearing from young people directly, our understanding remains limited to how behaviors are observed rather than how they are experienced internally.
For clinicians, this highlights the importance of approaching demand-avoidant behavior with curiosity rather than assumption.
4. PDA Is Most Often Studied in Autistic Children
Most participants identified as having PDA were also autistic. Several studies suggested that demand-avoidant behaviors may occur across the autism spectrum rather than representing a separate condition.
However, because comparison groups were limited or inconsistently defined, it remains unclear whether PDA reflects a unique profile or differences in emotional intensity, stress response, or environmental fit.
5. Anxiety May Play a Central Role
Several studies found associations between demand avoidance and anxiety, though anxiety was rarely assessed in depth.
Autistic children often experience anxiety differently from neurotypical peers, and distress may not always be obvious to adults. Sensory overload, uncertainty, novelty, and perceived loss of control may all contribute to heightened emotional responses.
From this perspective, extreme avoidance may function as a protective response rather than oppositional behavior.
Implications for Clinical Practice
The authors caution against using PDA as a firm diagnosis based on current evidence. Instead, they encourage clinicians to focus on understanding the child’s emotional and environmental context.
Helpful clinical questions may include:
What does this child find overwhelming?
How do uncertainty and unpredictability affect them?
What happens when expectations feel non-negotiable?
Which supports reduce distress rather than increase it?
Rather than asking, “Is this PDA?” it may be more useful to ask, “What is this behavior communicating?”
Moving Forward Thoughtfully
Kildahl and colleagues emphasize the need for future research that includes the perspectives of children and adolescents themselves, clearer definitions, and more careful exploration of anxiety and emotional regulation.
Until that research exists, PDA may be best understood as a descriptive term rather than a diagnostic conclusion.
Final Thoughts
This review does not dismiss families’ experiences. Instead, it reminds us that complex behaviors deserve careful, compassionate interpretation.
For mental health professionals, the central takeaway is this: children who strongly resist demands are not simply being difficult. Their behavior often reflects significant distress, fear, or overwhelm.
Whether or not the term PDA is used, supporting emotional safety, flexibility, and a sense of autonomy remains at the heart of effective and ethical care.