Pathological demand avoidance in children and adolescents: A systematic review.
Hold off on formal PDA diagnosis—current tools are parent-only, inconsistent, and lack child input.
01Research in Context
What this study did
Johnson et al. (2021) hunted every paper on pathological demand avoidance in kids and teens. They checked how researchers defined PDA and how they measured it. They also looked for any studies that asked the children themselves how they felt.
What they found
The team found big holes. Studies use different checklists, most rely only on parent report, and none include the child's voice. The evidence is too shaky to trust a formal PDA label right now.
How this fits with other research
Winburn et al. (2014) and Reilly et al. (2014) are two papers the review flags as weak. Both used parent-only ratings and loose criteria, exactly what the review criticizes. Egan et al. (2020) seems to clash at first: adults with ADHD traits scored high on self-report PDA scales, while the review says kids' PDA is poorly defined. The gap makes sense—adults can answer for themselves, kids usually cannot. Coe et al. (1997) and Dagnan et al. (2005) show that kids with developmental disorders often get ADHD or ODD labels. The review warns PDA could become another fuzzy label unless we fix the tools first.
Why it matters
Before you write “PDA” in a report, pause. Use clear behavior descriptions instead— “escapes demands when given three-step instructions” rather than “pathological demand avoidance.” Track demand escape by task length, clarity, and choice to build your own data while the field catches up.
Want CEUs on This Topic?
The ABA Clubhouse has 60+ free CEUs — live every Wednesday. Ethics, supervision & clinical topics.
Join Free →Replace the PDA label with measurable behavior—count how many two-step demands trigger escape and test if offering choice cuts the refusals.
02At a glance
03Original abstract
Requests for diagnoses of pathological demand avoidance have increased over recent years, but pathological demand avoidance remains a controversial issue. The concept of pathological demand avoidance has been criticised for undermining the self-advocacy of autistic people and neglecting the potential role of anxiety as a possible underlying or contributing cause. The current study was undertaken to summarise and review the methodological quality and findings from current research into pathological demand avoidance in children and adolescents. Further aims were to describe how pathological demand avoidance has been identified and to explore the relationships with autism and other developmental and psychiatric disorders. After a comprehensive search, 13 relevant studies using a wide range of methods were identified and systematic quality assessments were undertaken. All the studies had based the identification of pathological demand avoidance, directly or indirectly, on descriptions from the original study by Newson and colleagues. However, the methods used to develop these criteria were not clearly described. Most studies relied exclusively on parental report for data, and there was a general failure to take account of alternative explanations for the behaviours under study. No studies explored the views of individuals with pathological demand avoidance themselves. Problems concerning definition and measurement in the reviewed studies currently limit any conclusions regarding the uniformity or stability of the behaviours described, or the characteristics of individuals displaying them. Relationships between pathological demand avoidance and other emotional and behavioural difficulties should be explored in future research, as should the perspectives of individuals with pathological demand avoidance themselves.
Autism : the international journal of research and practice, 2021 · doi:10.1177/13623613211034382