How Applied Behavior Analysis Supports Children with Pathological Demand Avoidance (PDA) Profiles

By Julie Angstadt, MA, BCBA, LBS, IBA, Clinical Director of Hummingbird ABA Therapy

Pathological Demand Avoidance (PDA) is a complex and challenging behavioral profile seen in some individuals on the autism spectrum. Characterized by an overwhelming need to resist demands, PDA can lead to significant anxiety and avoidance behaviors (O’Nions et al., 2014). Children with PDA often experience intense stress when confronted with expectations, leading to behaviors like avoidance, aggression, and meltdowns. Historically, PDA has been misunderstood, often resulting in mislabeling these children as “defiant,” which can result in unnecessary and counterproductive punishment (Stuart et al., 2020).

ABA therapy, especially with compassionate and assent-based interventions, offers a structured, individualized approach that helps these children navigate demands more effectively and improves their daily functioning (Hanley et al., 2014). This post will explore how ABA can be used effectively to support children with PDA, helping them learn strategies to manage expectations, reduce anxiety, and develop more adaptive responses.

Understanding PDA: What Sets It Apart?

Pathological Demand Avoidance is recognized as a behavioral subtype within the autism spectrum (O’Nions et al., 2021). Its hallmark is a pervasive avoidance of everyday demands, from direct requests like “please put on your shoes” to subtler cues like a teacher handing out a worksheet. A child with PDA may also struggle with internal demands, such as addressing their own bodily needs. This avoidance is often so intense that it disrupts daily activities and may lead to challenging behaviors as the child seeks to escape these demands (White et al., 2022).

Children with PDA may employ various tactics to resist, such as making excuses, deflecting attention, passive resistance, or even aggression (O’Nions et al., 2021). These responses are primarily rooted in anxiety, as even familiar or preferred tasks can heighten stress when perceived as demands (Stuart et al., 2020). It’s crucial to understand that these behaviors aren’t simply “willful disobedience” but are deeply linked to the child’s anxiety and need for control.

How ABA Therapy Can Address PDA Behaviors

ABA therapy has traditionally focused on modifying behavior through reinforcement strategies. Over the years, however, ABA has evolved to incorporate more empathetic and child-centered approaches. This shift aligns well with the needs of children with PDA, who respond poorly to traditional reward and punishment systems. Instead, ABA for PDA emphasizes understanding the reasons behind a child’s behavior (the function) and gradually introducing supportive techniques to help them manage demands and reduce anxiety (Hanley, 2012).

Here are some key ABA techniques that are particularly helpful for supporting children with PDA:

1. Functional Communication Training (FCT)

For many children with PDA, communication difficulties exacerbate their anxiety. Functional Communication Training teaches them alternative ways to express their needs, such as asking for a break or politely declining an activity (Ghaemmaghami et al., 2021). By giving the child a safe, adaptive way to refuse or request accommodations, FCT reduces the need for avoidance behaviors and increases the child’s sense of autonomy.

2. Structured Environments

Children with PDA often struggle with ambiguity, which can lead to heightened anxiety. Creating a structured environment with predictable routines allows them to anticipate what will happen next. When demands are unavoidable, using clear schedules or visual supports can help a child feel more in control and less overwhelmed (Coffey et al., 2016).

3. Gradual Demand Tolerance Building

Introducing demands slowly and at a pace that respects the child’s comfort level is crucial for children with PDA (Slaton et al., 2017). In ABA, this process—known as demand fading or demand desensitization—begins with highly minimal or indirect demands and gradually increases as the child’s tolerance improves. This approach respects the child’s need to feel in control while helping them practice flexibility in a supportive manner.

4. Skills-Based Treatment

Skills-Based Treatment then builds on the PFA results to teach children contextually appropriate behaviors (CABs) through activities such as practicing turn-taking, following directions, and self-care tasks (Hanley et al., 2014). These skills are taught in a way that emphasizes the child’s control and choice, aligning well with the PDA profile. For example, a child can learn to request breaks or use coping strategies during high-anxiety situations, empowering them to respond constructively rather than avoidantly.

Practical Functional Assessment (PFA) and Skills-Based Treatment (SBT)

Developed by Dr. Greg Hanley, the Practical Functional Assessment (PFA) and Skills-Based Treatment (SBT) have proven to be valuable approaches within ABA for addressing complex behaviors. PFA involves an interview process to identify specific situations that lead to challenging behaviors, followed by creating an environment where the child can engage without the pressure of demands. This step is crucial for establishing trust and rapport, particularly important for children with PDA who may be apprehensive about therapy (Hanley, 2012).

Following the PFA, the ABA Case Supervisor can develop a Skills-Based Treatment approach customized to the child’s needs and preferences, while starting with finding what allows them to be Happy, Relaxed, and Engaged (HRE) (Hanley et al., 2014).

Importance of a Multidisciplinary Approach

While ABA can play a significant role in supporting children with PDA, research suggests that a collaborative approach is often the most effective (O’Nions et al., 2014). PDA stems from complex roots, including anxiety, sensory sensitivities, and social difficulties, and it’s best addressed through a combination of therapies:

• Cognitive Behavioral Therapy (CBT): CBT is effective for older children with PDA who can communicate verbally. It helps them reframe their thoughts about stressful situations, reducing anxiety and improving responses to demands (Stuart et al., 2020).

• Occupational Therapy (OT): OT can assist with daily life skills by helping children manage sensory sensitivities that often accompany PDA. By working on sensory processing and motor skills, OT supports children in becoming more comfortable with demands related to daily routines (White et al., 2022).

The strength of this multidisciplinary approach lies in each therapy’s focus on the child’s strengths and challenges, helping them to build a comprehensive set of coping skills.

By focusing on communication skills, creating predictable environments, and building demand tolerance, ABA helps children with PDA develop adaptive responses to everyday expectations. At Hummingbird ABA Therapy, we aim to empower children with PDA through individualized, neurodiversity-affirming ABA services, helping them gain the confidence and skills to navigate the demands of daily life. By working collaboratively with families and other professionals, we strive to make a meaningful difference in each child’s life, honoring their autonomy and providing the tools they need to thrive.

References

Ghaemmaghami M, Hanley GP, Jessel J. Functional communication training: From efficacy to effectiveness. J Appl Behav Anal. 2021 Jan;54(1):122-143. doi: 10.1002/jaba.762. Epub 2020 Sep 14.

Hanley GP. Functional assessment of problem behavior: dispelling myths, overcoming implementation obstacles, and developing new lore. Behav Anal Pract. 2012 Summer;5(1):54-72. doi: 10.1007/BF03391818. 

Hanley GP, Jin CS, Vanselow NR, Hanratty LA. Producing meaningful improvements in problem behavior of children with autism via synthesized analyses and treatments. J Appl Behav Anal. 2014 Spring;47(1):16-36. doi: 10.1002/jaba.106. 

Coffey AL, Shawler LA, Jessel J, Nye ML, Bain TA, Dorsey MF. Interview-Informed Synthesized Contingency Analysis (IISCA): Novel Interpretations and Future Directions. Behav Anal Pract. 2019 Apr 8;13(1):217-225. doi: 10.1007/s40617-019-00348-3. 

O'Nions E, Christie P, Gould J, Viding E, Happé F. Development of the 'Extreme Demand Avoidance Questionnaire' (EDA-Q): preliminary observations on a trait measure for Pathological Demand Avoidance. J Child Psychol Psychiatry. 2014 Jul;55(7):758-68. doi: 10.1111/jcpp.12149. Epub 2013 Oct 7. 

O’Nions, Elizabeth & Happe, Francesca & Viding, Essi & Noens, Ilse. (2021). Extreme Demand Avoidance in Children with Autism Spectrum Disorder: Refinement of a Caregiver-Report Measure. Advances in Neurodevelopmental Disorders. 5. 10.1007/s41252-021-00203-z. 

Stuart L, Grahame V, Honey E, Freeston M. Intolerance of uncertainty and anxiety as explanatory frameworks for extreme demand avoidance in children and adolescents. Child Adolesc Ment Health. 2020 May;25(2):59-67. doi: 10.1111/camh.12336. Epub 2019 May 22. 

White R, Livingston LA, Taylor EC, Close SAD, Shah P, Callan MJ. Understanding the Contributions of Trait Autism and Anxiety to Extreme Demand Avoidance in the Adult General Population. J Autism Dev Disord. 2023 Jul;53(7):2680-2688. doi: 10.1007/s10803-022-05469-3. Epub 2022 Apr 18.