Pathological Demand Avoidance (PDA) is characterized by extreme and persistent resistance to fulfilling typical demands or expectations from authority figures. PDA is largely driven by anxiety, and the resulting behaviors appear to be abnormal and excessive. These behaviors are not a choice, but a pattern of behavior specific to the child’s profile. PDA is closely related to Autism, with many diagnosticians believing it is a subtype or a profile of Autism Spectrum Disorder (ASD).
Applied Behavior Analysis (ABA) is an effective, evidence-based therapy approach used with autism spectrum disorder, and given that PDA is strongly correlated to ASD, it could also be a useful form of treatment for PDA. This article will explore the possibility and effectiveness of using ABA to treat PDA.
What is Pathological Demand Avoidance?
PDA represents a rare behavioral subtype of Autism that is characterized by an intense, obsessive inclination to resist or avoid demands. This tendency can result in sensory overload which can trigger meltdowns and outbursts of aggression. If a child with pathological demand avoidance is faced with a demand or an expectation, even minor or preferred, they will intensely attempt to escape the demand or expectation. Due to the difficulty in identifying and diagnosing PDA, children with it tend to be labeled as “defiant” and consequently receive excessive punishment.
Some types of demands a child with PDA might resist are:
- A direct demand – an instruction, for example, get your shoes on or do your math homework.
- An internal demand – this can include trying to get yourself to do something or satisfying bodily needs, such as hunger.
- An indirect or implied demand – an expectation, for example, a teacher placing a worksheet in front of a child.
Resistance or avoidance for each child with pathological demand avoidance looks different and can take numerous forms. Some types of learned behaviors exhibited by children with PDA are:
- Giving excuses that can seem outlandish – for example, “I can’t do my homework because I am a shark.”
- Distraction or diversion – this can include giving compliments or affection, changing the topic of conversation, or purposely creating a situation that would need attention, such as spilling a plate of food.
- Just saying “No” or physically resisting such as clenching their arms to their sides.
- Passively resisting such as becoming floppy, walking away, or daydreaming.
- Aggressive acts of refusal such as hitting, kicking, biting, or throwing things.
Aggressive outbursts are typically used by a child with PDA as a last resort. Elizabeth Newson, who coined the term Pathological Demand Avoidance in 2003, identified anxiety as the root cause of refusal, even if it is a preferred activity. As the child approaches the demand or expectation, the anxiety intensifies resulting in sensory overload, which can then produce aggression – the child’s ultimate effort to escape the situation.
PDA can impact a child’s executive functioning and create challenges that interfere with daily living. PDA can make it difficult to grasp the routine or structure in an environment. For example, in a classroom when the teacher hands out worksheets, it is expected that the child should complete the worksheet. However, the child with pathological demand avoidance may not realize this is the expectation and will draw their favorite character on the worksheet. Then when the teacher says, “You should be answering the questions on the worksheet, ” this demand seems sudden and out of place, resulting in resistance.
PDA can also create inflexible and obsessive behavior that can interfere with daily living. For example, if there is a sudden drop in temperature but a child with PDA refuses to wear sweaters before October, they will be cold and unable to change their pattern of thinking to wear a sweater.
PDA is not yet a formal diagnosis and many experts view the definition as too vague to be clinically useful. Dr. Martin, who studies and treats PDA, believes it should be identified as a behavior profile so children can receive effective treatment.
Does ABA Therapy Have the Tools to Help?
Historically, ABA has been used to effectively alter behavior through consequences, such as rewards and punishments. Rewards, such as praise or a tangible item, were provided following a preferred response. Punishments, such as ignoring or reprimands, were provided following nonpreferred responses. This method of implementation was heavily criticized, which created much-needed change in the field of behavior analysis.
Today, ABA has evolved to be more compassionate and provides choices that empower those receiving it to advocate their desires and feelings. ABA is now skills-based and occurs in happy, relaxed, and engaging environments. This methodology is better suited to treat PDA, which does not respond to traditional rewards and punishment.
The following are key aspects of ABA that can be used to effectively treat PDA:
- Functional Behavioral Assessment – identifying the function of the avoidance behavior and enabling the behavior therapist to tailor an intervention that directly meets the child’s needs.
- Functional Communication Training – teaching alternative or more adaptive ways for children to express their refusal. For example, asking for a break.
- Structured Environments – creating an environment that has a consistent routine that enables children to predict what will happen next.
- Positive Behavior Support – implementing reinforcement strategies that promote positive behavioral responses and reduce avoidance and challenging behaviors.
- Increased Toleration – systematically introducing demands at a slow rate to reduce the motivation to avoid tasks or demands.
- Social Skills Training – targeting social challenges specifically associated with PDA, such as classroom etiquette.
Is ABA Therapy for PDA Effective?
Most of the research on pathological demand avoidance pertains to identifying and assessing the profile of children with traits consistent with demand avoidance. This research has resulted in an extensive list of signs and symptoms of PDA and allowed practitioners to tailor questionnaires and assessment documentation to better identify PDA.
There is very limited research on the effectiveness of ABA or any form of treatment of PDA, however, BCBA practitioners have seen improvements in responding to demands or expectations using modified ABA techniques.
Board Certified Behavior Analyst, Dr. Greg Hanley believes it is possible to be free from problem behavior by teaching children the skills of communication, tolerance, and other appropriate behaviors during challenging situations that previously resulted in problem behaviors. Subsequently, he developed Practical Functional Assessments (PFAs) and Skills-Based Treatment (SBT) that can be used during treatment for PDA.
The first step is the PFA, which includes an interview designed to obtain information about the situation during which problem behaviors are present. Following this, the BCBA will create an environment where preferred items are freely accessible and there are no triggering demands or expectations. This environment allows the therapist to develop rapport with the child, ensure no problem behaviors will occur, and keep the child highly engaged.
The results of the PFA are used to create a skills-based treatment that consists of teaching communication, toleration, and contextually appropriate behaviors (CABs). For example, a child will be taught to ask for a break, to give an adult a preferred item they want to play with, to transition from play activities to work activities, follow the rules of a game, or do self-care activities such as brushing their teeth or getting dressed.
Success is based on repeated practice of the skill and access to reinforcement (rewards) on a spontaneous schedule. In addition, Nions (2021) reported that parents were more confident in treatment approaches that had high levels of involvement from professionals.
It is important to note that ABA treatment of PDA should be individualized and is most effective when used in conjunction with other treatment forms and not as a standalone treatment. ABA can be used alongside Cognitive Behavioral Therapy, Occupational Therapy, Speech and Language Therapy, and Physiotherapy.
Are There Alternative Therapies to Address PDA?
The best treatment for pathological demand avoidance is utilizing a collaborative approach. As noted earlier, the root cause of PDA is anxiety, which can be treated using Cognitive Behavioral Therapy. This form of therapy will help children reframe their thoughts about a situation which subsequently changes their actions in that situation. This form of therapy is best suited for children above the age of 7 who have substantial language and communication abilities.
Occupational therapy is an evidence-based treatment that works to improve the daily life of children with developmental disabilities. Pathological demand avoidance can impact a child’s ability to function as it makes it difficult for children with PDA to perform daily tasks, such as brushing their teeth or eating food that was placed in front of them. Occupational therapy can be used to reduce the sensory stimulation experienced by children with PDA when presented with a task or demand and better allow them to perform daily tasks. This form of treatment can be started as young as three, and there are no language requirements.
Speech and Language Pathologists are best suited to teach children with PDA functional communication. This can be verbal or augmentative and alternative communication (AAC). This form of therapy can teach a child with PDA an adaptable way to refuse a demand and empower them to express their desires.
However, the most important component of PDA treatment is responsiveness. Avoidance will fluctuate regularly, and care professionals should be aware of triggers and be able to recognize increases in anxiety and adapt their strategies accordingly.
ABA techniques can be modified and utilized in the treatment of pathological demand avoidance. PFAs are essential in establishing rapport with the child and identifying the function of the avoidance behaviors. This information can drive the development of a skills-based treatment that will teach the child with PDA the necessary alternative behaviors. These behaviors can be used to obtain the same or similar results as the previous challenging behaviors. However, ABA is best used in conjunction with other therapies, such as Cognitive Behavioral Therapy, Speech and Language Therapy, Occupational Therapy, and Physiotherapy.
The goal is to identify the child’s unique strengths and challenges and align them with the professionals who will support their autonomy and teach them the necessary skills to navigate their environment. This will look different for each child. Older children with better communication skills can benefit from Occupational Therapy and Cognitive Behavioral Therapy, while younger kids with limited language capabilities can benefit from ABA, Occupational Therapy, and Speech and Language Therapy.
Hanley, G. P. (2012). Functional assessment of problem behavior: Dispelling myths, overcoming implementation obstacles, and developing new lore. BAP, 5, 54-72.
Hanley, G. P., Jin, C. S., Vanselow, N. R., & Hanratty, L. A. (2014). Producing meaningful improvements in problem behavior of children with autism via synthesized analyses and treatments. JABA, 47, 16-36.
Santiago, J. L., Hanley, G. P., Moore, K., & Jin, C. S. (2016). The generality of interview-informed functional analyses: Systematic replications in school and home. Journal of Autism and Developmental Disorders, 46, 797-811.
Jessel, J., Hanley, G. P., & Ghaemmaghami, M. (2016). Interview-informed synthesized contingency analyses: Thirty replications and reanalysis. JABA, 49, 576–595.
Slaton, J. D., Hanley, G. P. & Raftery, K. J. (2017). Interview-informed functional analyses: A comparison of synthesized and isolated components. JABA, 50, 252–277.
Ghaemmaghami, M., Hanley, G. P., Jessel, J. & Landa, R. (2018). Shaping complex functional communication responses. JABA, 51, 502-520
Ghaemmaghami, M., Hanley, G. P., & Jessel, J. (2021). Functional communication training: From efficacy to effectiveness. Journal of Applied Behavior Analysis, 54(1), 122-143.
Stuart. et al., (2020) Intolerance of uncertainty and anxiety as explanatory frameworks for extreme demand avoidance in children and adolescents. Child and Adolescent Mental Health, 25(2), 59-67.
White, et al., (2022). Understanding the Contributions of Trait Autism and Anxiety to Extreme Demand Avoidance in the Adult General Population. Journal of autism and developmental disorders, 1-9.
O’Nions, et al., (2021) Extreme Demand Avoidance in Children with Autism Spectrum Disorder: Refinement of a Caregiver-Report Measure. Advances in Neurodevelopmental Disorders, 5, 269–281
O’Nions, et al., (2014) Development of the ‘Extreme Demand Avoidance Questionnaire’ ( EDA ‐Q): preliminary observations on a trait measure for Pathological Demand Avoidance. Journal of Child Psychology and Psychiatry, 55(7), 758-768