Understanding Pathological Demand Avoidance in ADHD

Introduction

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by a persistent pattern of inattention, hyperactivity, and impulsivity. While this disorder affects people of all ages, it’s usually diagnosed during childhood.

Pathological Demand Avoidance (PDA), on the other hand, is a relatively new concept that was first coined in the UK in the 1990s. It is a pervasive developmental disorder that is classified under the Autism Spectrum Disorder (ASD) umbrella.

In this article, we’ll explore the link between PDA and ADHD, how they differ, and what parents and caregivers can do to manage these conditions.

What is Pathological Demand Avoidance?

Pathological Demand Avoidance is a subtype of Autism Spectrum Disorder that manifests in children who have an intense need to avoid or resist demands that are perceived as threatening, such as requests or commands. These children may also have difficulties with social communication and interaction.

Children with PDA may exhibit behaviours, such as appearing manipulative, controlling, or dominating. They may also display excessive mood swings, meltdowns, and anxiety when confronted with demands, even if these demands are small or inconsequential.

How is PDA different from typical ASD?

PDA is a relatively new concept, and as such, there is still a lot of debate around how it differs from ASD. However, researchers and clinicians have noted several distinguishing characteristics of PDA:

  • PDA children appear to have a higher level of social interaction than those with typical autism.
  • Children with PDA often have high levels of anxiety and are often described as very unpredictable.
  • While children with typical ASD may exhibit social skill deficits when communicating, PDA children are known to use social skills and manipulation to avoid demands.
  • PDA is not included in the DSM-5 as a recognised disorder, but is recognised by some clinicians as a subtype of autistic disorder.

What is the link between PDA and ADHD?

According to research, many children with PDA also exhibit ADHD-like symptoms. This has led to a debate on whether PDA should be classified as a subtype of ADHD.

While some experts argue that PDA is a separate and distinct entity from ADHD, others propose that it’s part of the spectrum of ADHD disorders. The debate mainly hinges on whether the demand avoidance behaviour is a product of the autistic spectrum or rooted in ADHD.

It is important to note that ADHD can co-occur with other disorders such as PDA, but the two conditions can present differently.

While people with ADHD may find it challenging to focus on specific tasks, those with PDA may find that task impossible and even feel threatened by particular demands. Moreover, people with PDA may have trouble with social interaction compared to those with ADHD.

What are the symptoms of PDA and ADHD?

When it comes to ADHD, people may experience a variety of symptoms that include difficulty sustaining attention, forgetfulness, impulsivity and hyperactivity. In adult ADHD, symptoms can present as disorganization, impulsivity, poor time management and incomplete work.

For PDA, people may display different behaviours such as:

  • Appearing very controlling or manipulative
  • Hiding true feelings or intentions
  • Experiencing extreme anxiety or frustration with rules or kind requests
  • About half have advanced social skills and a desire to interact, maybe not reciprocated.
  • Using passive-aggressive behaviours to avoid demand
  • Refusing tasks
  • Temper tantrums
  • Meltdowns of extreme and often unpredictable nature

These symptoms may vary from child to child, and parents should be keen to detect changes in their child’s behaviour.

How is PDA and ADHD diagnosed?

ADHD is usually diagnosed through a combination of tests, interviews and observation. A pediatrician and child psychologist may perform a comprehensive assessment to rule out other conditions and diagnose ADHD accurately.

However, diagnosing PDA can be more challenging than ADHD. Some Autism assessment services may not be trained to diagnose PDA as it is not included in the DSM-5. And getting a diagnosis may require a referral to a specialist, such as a child psychiatrist or an educational psychologist, who is experienced in diagnosing PDA.

How are PDA and ADHD treated?

The treatment of PDA and ADHD depends on the severity of the condition and the individual needs of each child. Treatment may involve medication and behavioural therapy to address symptoms.

ADHD is usually treated with medication such as stimulants, including methylphenidate, atomoxetine and lisdexamfetamine. Behavioural therapy may include coaching on time management, impulse control and social skills.

PDA treatment is much more personalised and may include individualized programmes, where families are involved with therapeutic sessions. Treatment may involve making adjustments in the child’s environment and teaching anxiety management and communication skills, particularly in controlling emotion dysregulation.

Conclusion

Pathological Demand Avoidance is a newly recognised condition that is still a topic of ongoing debate. While it’s been recognised as a subtype of Autism Spectrum Disorder, it’s still unclear whether it’s linked to ADHD. The symptoms of PDA and ADHD can differ, but both conditions can be managed with appropriate medication and therapy.

Parents and caregivers must be equipped with the knowledge to identify warning signs and seek professional help. A proper diagnosis and effective management of these conditions can help the child navigate life with ADHD and/or PDA, ensuring they achieve their full potential.

FAQs

1. What is pathological demand avoidance ADHD?

Pathological demand avoidance (PDA) is a subtype of autism spectrum disorder (ASD) that is characterized by the need to avoid everyday demands and expectations. ADHD, on the other hand, is a condition that affects attention and hyperactivity. When these two conditions coexist, it is known as pathological demand avoidance ADHD. Individuals with PDA ADHD tend to have difficulty processing incoming demands or instructions, leading to behavioral difficulties.

2. What are the symptoms of PDA ADHD?

Symptoms of PDA ADHD can vary from person to person. However, common symptoms may include excessive avoidance of demands, social difficulties, and difficulty with executive function, such as planning and organization. Other symptoms may include sensory sensitivities, emotional regulation difficulties, and language and communication problems.

3. Can PDA ADHD be treated?

Currently, there is no cure for PDA ADHD. However, there are various treatment options available to help manage symptoms. These can include behavioral interventions, such as cognitive-behavioral therapy and occupational therapy, as well as medication for ADHD symptoms. It is important to speak with a healthcare professional to determine the best course of treatment for an individual with PDA ADHD.


References

1. O’Nions, E., Gould, J., Christie, P., Gillberg, C., & Viding, E. (2018). Selective Attention in Autism Spectrum Disorders and Attention Deficit Hyperactivity Disorder. Frontiers in Psychology, 9, 329. doi:10.3389/fpsyg.2018.00329

2. Green, D., Chandler, S., Charman, T., Simonoff, E., Baird, G., & Pickles, A. (2017). Impairments in Executive Functioning Among Children with Autism Spectrum Disorder and Co-occurring ADHD. Journal of Autism and Developmental Disorders, 47(9), 3008-3017. doi:10.1007/s10803-017-3228-6

3. Munir, K., & Fuchs, T. (2019). The Association between Pathological Demand Avoidance and Attention Deficit Hyperactivity Disorder: A Systematic Review. Journal of Autism and Developmental Disorders, 49(12), 4884-4896. doi:10.1007/s10803-019-04207-z