By Professor Tony Attwood and Dr. Michelle Garnett
Pathological Demand Avoidance (PDA) is characterised by an extreme avoidance of everyday demands, such as complying with a request to put a coat on to go outside or have a shower. PDA is currently conceptualised by most clinicians and researchers to be a profile of autism, and is commonly associated with ADHD. Some clinicians believe that rejection sensitivity dysphoria (RSD) is typically part of the picture. The extreme avoidance of demands that is a hallmark of this profile is understood to be underpinned by a need to maintain autonomy and control at all costs, and by high levels of anxiety. There are many clear demands in an autistic person’s day such as “hurry up, come here, be quiet, eat your breakfast, look at me when I am talking to you.”
Muche of the research to date on PDA has focussed on what PDA is, how it differs from autism and anxiety disorders, and how to measure it. There has been little focus on the nature of the demands that cause the distress. Our clinical experience suggests that, in addition to more obvious demands, hidden demands in everyday interactions and internal demands can lead to high levels of anxiety and overwhelm, and therefore to avoidance. The hidden demands can include someone assuming what the PDAer* would like, giving praise or rewards, and asking the person to do something they had already decided to do. Internal demands can include needing to go to the toilet, to eat, or to fall asleep.
Hidden Demands
Assumptions
When someone assumes that they know what the PDAer wants or likes, it can feel to the as if they are being told what they would like or want and therefore that someone else is controlling their choices, thoughts, and feelings. The PDAer needs to make their own choices to feel in control, to increase their sense of autonomy over their life, and to decrease their anxiety.
What may help…
- Giving the PDAer choice over what to do, or when or how to do it.
- Understanding the PDA perspective and honouring their autonomy.
- Asking the PDAer about their preferences, likes and dislikes, since these may change from day to day.
- For the PDAer: Explaining that their likes, dislikes and preferences change from day to day.
Praise
Being praised might make lead the PDAer to feel pressured to do the same thing again in the same way, and they may feel that they cannot possibly do that. Praise can be perceived as an attempt to impose control. We have found that many PDAers consider praise to be an experience to avoid.
What may help…
- For the person who wants to give a compliment: Explaining that when you give compliments, you do it because you want them to feel good about themselves. Asking them if there is a compliment that would feel good for them to hear from you.
- For the PDAer: Saying to the person praising, ‘Thank you, but I am not sure I could do it again.’
Rewards
Rewards may not be as effective as anticipated because rewards can increase pressure and expectations, making the task feel even more difficult and overwhelming, and increasing performance anxiety.
What may help…
- For the PDAer: Explaining to those that need it how they feel about the pressures of a reward and ask not to be offered a reward.
- Doing a task can sometimes be reward enough.
- For the person wanting to give rewards: Asking the PDAer if rewards would help, and if they could be helpful, what sorts of rewards?
Imposing a demand when the person had already decided to complete that task.
If someone tells a PDAer to do something that they were already going to do, then the perception of an imposed demand and losing autonomy may stop them from doing it, causing distress to the PDAer and confusion for the person who asked.
What may help…
- For the PDAer: Explaining to others how they appreciate choice in what happens next.
- For the person asking: Understanding the PDA perspective and adjusting communication to allay fear and pressure.
Internal demands
Internal demands are internal sensations that interrupt thought and require that an action be taken. For example, feeling hungry or thirsty and needing something to eat or drink, needing to sleep, or to go to the toilet. These are demands imposed by the body and at times can be perceived as being stress-inducing as external demands.
What may help the PDAer…
- Prioritising the body’s demands and choosing when to respond.
- Seeing the body as being part of self-identity.
- Knowing that the body deserves to be treated well as if it were a good friend.
* Many autistic people with the PDA profile prefer the term, PDAer, hence our use of the term here.
Where to from here?
If you are new to PDA and wish to know more, we recommend attending our three-hour upcoming live webcast, PDA: An Introduction. On the same day, we will present a second three-hour course that assumes knowledge about PDA and explores a deeper understanding of the profile, strategies, and support: PDA Going Deeper. We hope you can join us.
