Bill Klaproth (Host): This is The Peds Pod by Le Bonheur Children's Hospital. I'm Bill Klaproth. And with me is Dr. Donald Bearden, Division Chief of Psychology and Behavioral Health, Associate Professor in Pediatric Neurology at Le Bonheur, as we discuss, is your child defying your request or is it pathological demand avoidance or PDA? Dr. Bearden, welcome.

Dr. Donald Bearden: Good morning, Bill. It's great to be here. Thanks for having me.

Host: You bet. Always great to talk with you. So Dr. Bearden, let's start with this, can you explain to us what is pathological demand avoidance or PDA? And can you maybe give us a few examples?

Dr. Donald Bearden: Sure. So, think of PDA as an anxiety-driven pattern where everyday expectations feel threatening. So, the child tries to regain control by avoiding demands, including things they actually want. It's commonly described as a profile within autism, rather than a standalone diagnosis. And it's not recognized in any of our diagnostic classification systems such as the DSM-5 or ICD-11, which is why it stirs a bit of debate.

So, some examples are children who will avoid at any cost engaging in any type of activity that feels like a demand. And rather than using anger-based tactics like aggression, yelling, things of that nature, they'll actually use fairly sophisticated social strategies like distraction, charming, trying to charm someone, role playing, things of that nature.

Host: That's really fascinating. So, I just want to dig into this a little bit, Dr. Bearden, just so I fully understand this. So if you say, "Hey, Johnny, we're going to your sister's basketball game," like, it's a simple request. "We're going to support your sister," that may feel like a demand to that child?

Dr. Donald Bearden: For a child with PDA, that's going to feel like a demand, and they're going to probably do everything they can—from a social strategy perspective—do everything they can to try and get out of that. So, they may say something like, "Oh, well, look over there. What's happening over there?" or "Let's play this game. Let's do this," or asking you a question about something they already know, something to change the topic. Or they may try role playing like, "Well, first you do this, and then I'll do that, and then you do this," to try and delay, having to go through with what's being asked. So, those are some types of examples of things that might come up.

But to be clear, what they don't do typically is any type of what we typically think of as a defiant anger-based reaction, like yelling, throwing things, getting aggressive, things of that nature that we would consider more common in a typical defiant disorder like oppositional defiant disorder.

Host: Okay. So, they're not going to get mad. "I am not going to my sister's basketball game." They're going to try to deflect and change the topic and try to get you to focus on something else.

Dr. Donald Bearden: That's it. Because with oppositional defiant disorder or ODD, typically, those are more power struggles, anger and power struggles. So, we will see those types of reactions. For our kiddos with PDA, it's much more often that they're going to respond with some sort of social strategy.

Host: Wow. So, I would imagine that includes chores too. "Hey, it's time for you to do the dishes," or "Time to clean the table," that kind of a thing too?

Dr. Donald Bearden: Absolutely. And what's interesting and what is really one of the indicators that you're dealing with PDA rather than ODD is that it could be something that they actually like doing that you know. "Hey, let's go see a movie," or "Let's watch a streaming video," or "Let's play this game that I know you like." Anything, whether it's something they enjoy or not, you're going to have a similar reaction if it's not handled in a way that's more thoughtful when dealing with kiddos with PDA. Compare that to ODD, where ODD, typically, they're really resisting the tasks that they don't want to do, like homework, things of that nature.

Host: Okay. So, they don't want to be told what to do or even suggested, "Hey, let's go see a movie." "Hey, no, I got this to do." "Well, what about this? How come—?" So then, that's the kind of back and forth you're getting into.

Dr. Donald Bearden: That's right.

Host: Wow, this is really interesting. So, Dr. Bearden, why does this happen? What's going on?

Dr. Donald Bearden: Truthfully, we don't know. I think that there's still a lot of studies to be done. So, the current research that's been done is highly variable. It's really based mostly on parent report and without a shared standard.

And so, a little bit of backstory there, Bill, Elizabeth Newson first described the pattern of what we call PDA in the 1980s. And since then, the field has wrestled with where it fits. The research base is growing. But as I said, it's variable. And many studies rely on parent report, and they use a criteria inspired by Newson rather than a shared standard. And so, you'll see measures like something called the Extreme Demand Avoidance Questionnaire, or another one is disco interview modules, which are informative but not clinically standardized. So, all of that fuels the ongoing debate about whether PDA is a distinct condition. Is it a subtype of autism or is it a manifestation of other factors like severe anxiety? And I would say we just don't know yet. And because it's not in the U.S., it's not a diagnosis. And it doesn't exist within our diagnostic classification system. It makes it even more murky and difficult to do research on.

Host: Yeah. And you said demand avoidance is not lashing out, getting angry, defiance, is that right? This is more of an intellectual back and forth.

Dr. Donald Bearden: Yeah. So again, with the PDA, the primary driver is anxiety and a need for self-control, not anger or a power struggle. Kids often avoid even enjoyable activities simply because someone suggested it, which makes it feel more like pressure. And the avoidance can be remarkably social and sophisticated, as I mentioned before.

One other thing to mention, Bill, that distinguishes it from defiant disorder is that there's a lot of variability across environments. So in context where a child feels safe and in control, behavior looks much easier. But where control feels threatened, you'll see avoidance spike. And traditional behavior systems that rely on rewards and consequences often will backfire, because even rewards feel like demands to these kiddos.

Host: Wow, that's really interesting. All right. So, you said there's a lot of variability in this. So then, how do you know? What are some signs that your child may be experiencing PDA?

Dr. Donald Bearden: So, ODD or defiant disorders, typically characterized by irritability, anger, and vindictiveness; whereas PDA revolves around anxiety control needs, and a global demand sensitivity. This idea of global demand sensitivity means that it doesn't matter whether it's something they typically enjoy doing or something they would rather not do. You're going to see the same level of demand sensitivity regardless, and you don't see that in ODD.

Also, there is overlap with ADHD and autistic profiles without PDA, in that they can share some executive functioning difficulties, some self-regulation challenges. But they typically don't show the same pervasive anxiety-driven avoidance of demands. And these interesting social strategies that are often layered on top, you don't see those in defiant disorders, ADHD or autistic profiles without PDA. And so, that helps us differentiate.

Host: So if a parent feels like, "Hey, my child seems to be showing symptoms of PDA, what can you do then? How do you help your child?

Dr. Donald Bearden: Interventions or parent behaviors that lower perceived pressure tend to help. That means indirect or invitational language, genuine choice and flexibility, predictable routines, transition planning, and sensory supports. So, you want to replace public praise with private acknowledgement to avoid performance pressure. You want to start with low demand entry points, so getting your foot in the door and then gradually ramp up. And most importantly, focus on connection and co-regulation rather than compliance. So, connecting with the child and collaborating to help them regulate their emotions, their anxiety, that's going to get you further than trying to get them to comply.

If a strategy hinges on rewards or punishments, as a parent, I would really ask whether it might feel like more pressure to this child, because often the answer is yes. And in those situations, I think you're going to go round and round. And it's going to be very frustrating for both sides.

Host: I could see where that would be very frustrating. So back to the example, "Johnny. We're going to go watch your sister play basketball tonight." How would you rephrase that then?

Dr. Donald Bearden: Right. So, you could say something like, "Johnny, we have a couple of options on the table. What do you think about going to watch your sister's game tonight? Another option could be that we do this other thing." So, you would want to make it more of a choice and you would want to have some built-in safety nets, if you will, so that if the child in that moment doesn't want to go to their sister's game, so the option is that they don't go.

So, you want to, again, do it collaboratively, offer choices where possible. I mean, as with any kind of significant behavioral issue, whether it's PDA, ADHD, autism, ODD, certain plans have to be put in place. So for PDA, you want it to be collaborative, you want to offer choices, and you want to watch the way you frame it to the child so that it feels collaborative, it feels like a choice. And that's the best strategy in these situations when working with kids with PDA.

Host: Okay. I'm making this difficult on you, Dr. Bearden, today. So, bear with me. Okay. Johnny is 10. He can't stay home alone. "We're going to see the sister's basketball game tonight. There is no option. You're coming with. You're 10, you're nine. You're not old enough to stay by yourself and we're not getting a babysitter. We're going to your sister's game tonight." In that case, do you say, "Hey, we're going to go watch your sister play basketball tonight. But when we get there, if you want, we can get some popcorn and a drink. And maybe afterwards, we'll go for some ice cream." Would that be a way to do it?

Dr. Donald Bearden: So, yes, you're definitely on the right path, Bill. I might change that to explain the situation, and to use softer language, right? So even in your language. "So, Johnny, your sister has a game tonight and we're all excited to go and see her. Once we're there, you'll have the option of watching the game, or you and dad can go for a walk," rather than framing it immediately off the bat. Because if you do that, if you can soften your language—because imagine you're the child, right? And any type of demand provokes uncontrollable, intense anxiety.

From baseline, you want to start with softer language. You want to explain more. You want to identify the choices the child will have. Certainly, you're going to identify that there are no other options if the child brings it up. But I wouldn't lead with that. Because if you don't, then you're already triggering the avoidance response. And so, you're giving yourself a lot more work than maybe if you softened your language. And again, make it less of a demand and more of, "Here's what your options are," but just not offering anything that you can't offer because you don't have the option, if that makes sense.

Host: Do kids grow out of this? Because I would imagine this would be very difficult when Johnny, our fictitional child, gets into the working world. And the boss says, "I need this at five. You better have it ready at five." And there's bad bosses out there. "I don't care, Johnny, about what you're doing. I need this now." And the PDA kid is like, "You're not telling me what to do. I'm going to get into a give and take. Well, what about this?" And the boss is going to be like, "I'm done with you, dude."

Dr. Donald Bearden: What I would say to that is we still need more longitudinal research to clarify the developmental course. We just don't have enough information. So unfortunately, we just don't have that information yet that I'm aware of.

Host: Right. Very interesting. Okay. So, when should parents then seek additional help if they're really frustrated or at wit's end?

Dr. Donald Bearden: Right. Ah, because there's a really important point here that I haven't mentioned yet. That is something that these families that are dealing with PDA experience a lot of frustration and misinterpretation. And they report that it's an exhausting cycle.

Professionals often view the pattern through what we call a neuronormative lens rather than a neurodivergent lens, and they'll conclude that the child's oppositional or that it's a parent problem, parenting is inconsistent. They kind of blame it on the parents. And that mismatch, Bill, leads to strategies that intensify avoidance and distress, parents report isolation, stigma, and a lot of blame. So, the pivot point is validation. When they encounter a PDA-informed framework, families often feel immediate relief and finally get strategies that are protective rather than provocative, right? And so, even though we don't have the diagnosis, it's not a formal diagnosis in our classification system. And what that leads to is that a lot of providers, psychologists, psychiatrists, they're just not aware of it.

If you think your child might be dealing with PDA, you don't need to lead with that. And I would advise not going to the doctor and saying, "My child has PDA, and this is what it is." And rather than focusing on a diagnosis, you would want to report to the mental health specialist that you would like to work with your child about the underpinnings of the behavior. So, saying things like, "Johnny just is so anxious. It could be something we know he loves, and the moment we just suggest it and say, 'Hey Johnny, let's go to the movies and let's go get ice cream,' we know he loves it, but the moment we say we're going to do that, the moment we suggest it, he immediately starts in with these excuses. He tries to get us off topic. He tries to play games with us, all this stuff. And it doesn't matter, it could be something we know he loves. We also see that it's not always that way. Sometimes when we're at home and it's just mom and me and him, there's no problem, but the moment that we have a guest or the moment that a sibling steps in, then he starts in with the excuses and just tries to avoid it again."

So, you're really getting at the core features of it without saying, "Hi, Doctor. My child has PDA. What do we do about this?" Because, unfortunately, the chance is that that specialist will not have heard of PDA and might even consider that it's something fictitious made up or doesn't have it an evidence base. And then, they'd be back in that cycle of being misinterpreted, misunderstood, and having them be blamed for the problems.

Host: Right. So, is demand avoidance something new that we're learning?

Dr. Donald Bearden: So, probably not. As I mentioned, Elizabeth Newson came up with this in the 1980s. And the field has really struggled with it. Because I think in some places in Europe, it has been identified, it is considered within their diagnostic classification framework. It is not the case in the United States. And so, that has just been very, very problematic. But as with many things like ADHD and autism, these things have been around long before there was a diagnosis for them.

Host: So, what are your tips then for parents? You've already gave us some strategies. If a parent is listening to this and saying to themselves, "Oh my gosh, my child is exhibiting the signs of PDA," what do you say to that parent?

Dr. Donald Bearden: I would say that you really want to work in a collaborative way that helps your child manage their anxiety and their need for control. Parents are the experts on their child, so you want to do anything you know that will lower your child's baseline anxiety. So, knowing your child, what do you know is going to immediately help reduce their anxiety. You want to create as much predictability and comfort as you can in daily life. You want to reduce the intensity of unexpected input to the degree that you can, I mean, this is life, right? So, parents can't control everything. But to the degree that they can, reducing the intensity of unexpected input, regularity, predictability and comfort support, emotional regulation. Help your child to emotionally regulate themselves.

So when parents see their child getting really anxious and start to use avoidance strategies, distractions, step back, help them to the degree that parents can help them lower that anxiety, knowing their child. And then, help make demands feel less threatening, So, collaborative choices, choosing words carefully; rather than demanding, offering a choice. When there really isn't a choice available, try and find areas where there could be more flexibility.

And then, also, a lot of our kiddos with PDA have sensory sensitivities. Children with ADHD and children with autism also will have these with autism without PDA. So, oftentimes these children will have sensory sensitivities to touch, to movement and balance, to sound, visual stimuli. And depending on your child, you probably, as a parent, already know what those are. But for children who have proprioceptive sensory issues, a weighted lap pad or shoulder wraps, wall pushups, chair pushups; for vestibular sensitivities, some sort of rocking chair, gliders, a hammock, slow spinning, gentle bouncing. By the way, these things could be used to help them to get to their baseline, to lower their baseline anxiety, to calm down, to regulate themselves. These types of things are good for that. Some tactile options are fidgets, soft clothing, sensory bins like rice beads, water beads, warm compresses. And then, auditory sensitivities, things that manage those well include noise-reducing headphones, predictable background noise warning before loud or sudden sounds. Visually, dimmer lighting, lamps instead of overhead fluorescence. Some visual schedules. Another one is minimal visual clutter in workspaces. So, those are just some options, but those can help to lower baseline anxiety in these kiddos.

Host: Yeah. Those are some really good examples of things parents can do. As you said, work in a collaborative way. Do what you can to lower anxiety. Try to create predictability, reduce unaccepted input, support emotional regulation. Those are really good. It sounds like parents have to be skilled and patient at this, because I could see after a long day and it's like, "Hey Johnny, we're going to see your sister play basketball." And then, it starts up. The response would be like, "This is not a big deal. This is what we do. It's a game. It's a basketball game. Deal with it." I could see where it would take a lot of patience on the parents' part to get into this. "Okay, I've got to be collaborative. I've got a lower anxiety now." I could see where parents have to be, again, skilled and patient at the same time.

Dr. Donald Bearden: Right. Now, that's true, Bill. But I would point out just to normalize it a little bit, that we make accommodations for our children with ADHD. And we make accommodations for our children with autism and many other, ODD, you know, all the different types of developmental disorders that exist. And this has yet to be shown to be a developmental disorder.

I will add that caveat, but it's similar in that parents have to prepare, have to plan for raising kiddos with these that are neurodivergent. And so, in that way, we're fortunate the research that's been done with autism has really blazed the trail. And so, a lot of these recommendations have been forged through that or created through that and are definitely applicable to our kiddos who are experiencing PDA. And so, I think, for the better or for worse, these are things we have to do when we're raising a child who's neurodivergent. Yeah.

Host: Absolutely. And the tips that you gave us really can help and that's what's important. Because you don't want to get into fights and arguments or isolation. "Oh, just let him do what he wants to do. You don't want to get into that." So, these tips that you gave us really are important. Before we wrap up, any final thoughts, Dr. Bearden?

Dr. Donald Bearden: I would say, just remember relentless demand avoidance can be an anxiety response, not a discipline problem, not a defiant disorder. And second, when we protect autonomy and lower the pressure behavior often becomes workable for these children. So if you keep those ideas in mind, you'll choose supports that help rather than harm your child.

Host: Great way to wrap up. Awesome thoughts. Dr. Bearden, this has been wonderful. I'm sure this has helped a lot of parents. Thank you so much for your time and information today. We really appreciate it.

Dr. Donald Bearden: It's my pleasure, Bill. Thank you for having me.

Host: You bet. And once again, that is Dr. Donald Bearden. And be sure to subscribe to The Peds Pod on Apple Podcast, Spotify, or wherever you listen to your podcast. You can also check out lebonheur.org/podcast to view our full podcast library. And for more information on this and other things, you can always visit lebonheur.org. And if you found this podcast helpful, please share it on your social channels. This is The Peds Pod by Le Bonheur Children's Hospital. Thanks for listening.