Understanding Pathological Demand Avoidance (PDA) in Children

Does your child really have PDA (Pathological Demand Avoidance)?

The parents of a young acquaintance of ours, aged 4, were recently told by a psychologist that their son displayed signs of PDA (Pathological Demand Avoidance). 

If you explore PDA you will find that it is characterised by persistent, indeed wilful, refusal to comply with adult requests and may often be associated with emotional outbursts or ‘meltdowns’ when a child is required to modify their behaviour. 

My little guy, for example, will only eat Wheaties and, to use an old-fashioned term, ‘cracks a fruity’ if told that it is dinner time and breakfast cereal is off the menu.

Children labeled with PDA may also be described as being ‘socially manipulative’; in other words, they have learned to play on the heartstrings of anxious parents to get what they want. Even more confusing for parents is that a child may display PDA-type behaviours at home but not at school. 

PDA is also, occasionally, observed as part of a broader pattern of behaviours associated with Autism Spectrum Disorder (ASD). 

At this point it must be emphasised that PDA is not a formal clinical diagnosis and does not appear in DSM IV (the global standard for diagnosing mental disorder). Furthermore, there is no body of research evidence to suggest it should be described as any kind of psychological ‘condition’.

Nevertheless, it, and labels like it (Oppositional Defiant Disorder or ODD for example) is becoming increasingly used to pathologise or medicalise what, in the past, parents and clinicians would have regarded as normal albeit unpleasant behaviour in young children. If you have raised a toddler, you will know that one of their favourite words is “No!”

The trend towards the medicalisation of everyday ‘disruptive’ behaviour in normal kids is apparent in the explosive growth of psychosocial disorders such as Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD), particularly in boys. Today 12% of all boys and 5% of all girls in Australia aged 5 to 7 are on NDIS programs for psychosocial disorders, particularly ASD, and these numbers continue to rise.

While severe autism does occur the use of a spectrum or continuum approach to diagnosing ASD has rendered the label close to useless because of the way it is used to encompass too many individuals ranging from a minority with a genuine disability to the vast majority of normal kids who ‘play up’ from time to time; that is, who display temporary behavioural irregularities.

The National Council on Severe Autism in the US is highly critical of spectrum theory stating that “The broadening of the construct of autism in the form of the Diagnostic and Statistical Manual criteria for Autism Spectrum Disorder in 2013 has had the effect of rendering the diagnosis essentially meaningless, as it allows for the same diagnosis to be given to wholly disparate individuals”. 

Apparently even Lorna Wing, the psychiatrist who coined the term “Asperger’s Syndrome” (a previous name for ASD) came to regret this since it has become such a loose descriptive label,  covering too many dissimilar behaviours, so as to be meaningless for diagnostic purposes. In other words, it does not effectively distinguish between a minority of children with a genuine mental disorder and the vast majority whose behaviour may create concern for parents and others from time to time but who are clearly not ‘autistic’ and should be not labeled as such.

What is happening? Well, essentially there is a fashion in Western countries for labeling ‘difficult’, ‘bad’ or ‘disruptive’ behaviour as ‘illness’ which gets teachers and parents off the hook when it comes to addressing this extremely common and normal feature of childhood.

The consequences for the kids thus labeled are potentially serious. The kid is diagnosed with ASD, regardless of how minor their behavioural issues may be, so that parents, teachers and others – despite their best efforts - come to expect and look for other ‘symptoms’ of ASD which, in turn, can turn what originally was a normal case of ‘misbehaviour’ into a full blown psychological problem. 

As Steve Biddulph notes “Children generally live up to our expectations”. To this, I would add that they generally live down to them as well. Parents need to be very careful what labels they – or allow others to - attach to their kids since these can have a nasty habit of becoming a self-fulfilling prophecy.

Angela Shanahan (who provides the detail on ASD above) argues in The Australian:  “Labels are one of the biggest obstacles to fully understanding neuro diversity, especially in so-called “high functioning” people whose problems are not particularly disabling” 

She concludes “We can’t continue to dress up mild psycho-social problems as disability”.

PDA and Anxiety

The argument for considering PDA as a psychological ‘problem’ rather than normal misbehaviour in a ‘ratty kid’ is that it is generated by anxiety associated with a fear of loss of control. Anxiety, it is suggested, leads to a child trying to dominate their surroundings using all the emotional tools at their disposal. And when they find that total control is impossible and their anxiety is no longer manageable they spill over into a ’meltdown’. 

But to regard anxiety as the root cause of PDA is to confuse cause with effect or condition with symptom. In the case of PDA anxiety is a symptom, not the condition itself. And by regarding anxiety and the ‘misbehaviour’ associated with it as the problem rather than as mere symptoms, parents may unwittingly prolong and exacerbate both.

Children become anxious and ‘act out ‘when they feel insecure, when they don’t know where the boundaries are or what is acceptable in a particular situation. We may regard them as naughty but they don’t! They are expressing a natural impulse to dominate the space around them as they work out what is possible in the exciting world into which they have emerged.

Just as they must learn (sometimes painfully) the boundaries that gravity imposes on their physical space so they must learn appropriate behavioural boundaries (imposed by parents, teachers, and others) in their social space if they are going to learn social desirability, that is, “… to comply gracefully with the expectations of civil society.” (Including not eating Coco Pops at dinner time).

Children who are not pleasant or easy to be around are shunned by their peers; even the adults responsible for their care – including their parents – will tend to avoid them. They are just too hard to manage or cope with.

Sustained rejection by others severely compromises a child’s psychosocial development (because a strong social network is integral to mental health) and significantly increases the likelihood of them becoming lonely and socially dysfunctional adults. 

Let’s be clear. Wanting children to be ‘socially desirable’ does not mean turning them into little sycophants who ‘suck up’ to people to gain their attention and approval. Nor does it mean that they become robots, simply conforming to the ideas and opinions of whomever they happen to be talking with at the time.

Rather it means to teach them, if necessary with discipline, to interact respectfully with adults and their own peers as well as with strangers so that they can build mutually rewarding relationships. This includes teaching them how to disagree appropriately with others as well as how to stand up for what they believe even if the weight of opinion is against them.

This is why children’s behaviour can be quite different at home than at school for example, which, as noted earlier, can be a feature of PDA. In a situation, school for example, in which social boundaries are clear and enforced with compassionate, reliable discipline kids soon become comfortable and feel secure (in the same way they quickly come to accept rather than resent gravity). Alternatively, in an environment in which boundaries are unclear or randomly applied they become anxious and uncertain: their anxiety is created (i.e. caused) by the failure of adults to provide clear and reasonable behavioural boundaries which, when necessary, are enforced through consistent discipline based on love and respect.   

PDA is not a psychosocial disorder and should not be diagnosed or labeled as such. It is one example of the multiple varieties of ‘misbehaviour’ normal kids display as they grow and learns how to navigate their social world. Parents have a primary responsibility to provide clear and reliable behavioural boundaries within which they can feel secure - and learn to socialise successfully with others - as they grow toward adulthood.

Dr Terence Sheppard (B.Ec., B.A. Psych. (Hons), PhD)

A Paediatric Psychologist and co-author of “Positive Parenting: Your Guide to Raising Psychologically Healthy Children”. Terence works in private practice and lectures regularly in psychology at the University of Adelaide.