What is PDA?
Pathological Demand Avoidance (PDA) is a profile of autism first described by Elizabeth Newson in the 1980s. The core feature is an anxiety-driven need to avoid demands — not out of defiance or laziness, but because demands feel genuinely threatening to the nervous system.
The word "pathological" is contested — many in the PDA community prefer terms like "Pervasive Drive for Autonomy" or simply "PDA profile." Whatever you call it, the experience is the same: ordinary expectations that most people navigate easily can feel impossible, overwhelming, or even dangerous.
This isn't about being "oppositional." People with PDA often want to do the thing — they just can't, not when it's framed as a demand. The demand itself triggers a threat response.
How PDA Shows Up
In Children
- →School refusal — not "won't go" but genuinely can't. The demand of school attendance triggers overwhelm.
- →Meltdowns over "easy" tasks — brushing teeth, getting dressed, homework that they clearly know how to do.
- →Social masking — appearing to cope in public, then falling apart at home where it feels safe.
- →Role play and fantasy — using imaginative play to process demands or create control.
In Adults
- →Burnout cycles — periods of pushing through followed by complete collapse.
- →Employment difficulties — struggling with workplace demands even when the work itself is enjoyable.
- →Avoiding even things you want to do — the demand itself is the problem, not the activity.
- →Difficulty with self-care — eating, showering, medical appointments become demands too.
PDA vs Other Presentations
| Feature | PDA | ODD |
|---|---|---|
| Root cause | Anxiety / threat response | Often trauma or conduct issues |
| Response to demands | Avoidance driven by overwhelm | Active defiance |
| What helps | Reducing demands, autonomy | Boundaries, consistency |
Why this matters: PDA is frequently misdiagnosed as ODD, leading to interventions that make things worse.
What Helps
Low-Demand Approaches
This doesn't mean "no expectations" — it means reducing unnecessary demands:
- Does this actually need to happen right now?
- Does it need to happen this way, or is there flexibility?
- What's the cost of not doing this vs forcing it?
Autonomy Over Compliance
- Offering genuine choices (not "do this or else")
- Indirect language: "I wonder if..." instead of "You need to..."
- Letting the person set the pace where possible
What Backfires
- Reward charts — turn activities into demands with performance pressure
- Consequences — escalate anxiety without addressing the root cause
- Countdowns and timers — create urgency that increases threat response
- Praise — can feel like pressure to repeat performance
How We Work With PDA at Estus Health
Low-Demand Therapy
Our philosophy isn't about compliance. It's about reducing pressure until the next step feels possible — however long that takes.
Gaming-Informed Approaches
Traditional therapy is full of demands. Gaming-informed therapy meets people in a space that already feels safe.
Lived Experience
Our team have lived expereince with Autism and PDA. We understand from the inside — not just from textbooks.