Pathological Demand Avoidance Test

## **What is pathological demand avoidance?** Also known as extreme demand avoidance, pathological demand avoidance (PDA) is a term for behaviors of individuals who go to great lengths to evade or ignore perceived "demands." You might call it extreme resistance. These "demands" can refer to everyday demands like getting dressed or completing a task, ordinary demands such as following instructions, and even internal demands, like personal expectations or responsibilities (Miller, 2024). While PDA is not formally recognized as a mental health diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM), it holds significant relevance due to its potential to cause functional impairment and impact an individual's overall quality of life. PDA was coined by Elizabeth Newson in the 1980s. The term initially identified individuals with pervasive developmental disorders (PDD) exhibiting distinct traits associated with demand avoidance. However, over time, the understanding of PDD has evolved, and it is now recognized as part of autism spectrum disorder (O’Nions et al., 2015). According to the National Autistic Society, while there is no formally recognized and separate PDA diagnosis, many individuals may be diagnosed with autism and have a "demand avoidant profile" or a "PDA profile" noted in their records. It is not required for an autism diagnosis, but it may help better understand certain behavioral traits. Signs of PDA manifest in behaviors that may seem obsessive, coupled with an intense need for control over the environment. One common misconception about PDA children is misidentifying these behaviors as mere defiance or oppositionality. It is crucial to note that demands are not solely verbal instructions; even subtle gestures or silent offerings can be perceived as demands. This nuanced understanding helps in distinguishing PDA from other behavioral issues. It's important to remember that PDA is not a one-size-fits-all concept. Its manifestation varies significantly across individuals, underscoring the importance of individualized approaches to diagnosis and treatment. Whether you're assessing adult or adolescent mental health, recognizing the diversity in how PDA presents itself is crucial in fostering understanding and providing tailored support for affected individuals, especially autistic children who have traits of PDA.

## **How is pathological demand avoidance assessed?** Pathological demand avoidance is often assessed using the Extreme Demand Avoidance Questionnaire (EDA-Q). It's the most popular tool for assessing PDA, though it's often used on adults aged 18+. It was created to assess people with suspected or confirmed autism spectrum disorder, oppositional defiant disorder, conduct problems, and disruptive behavior (O’Nions et al., 2013). ### **What to expect from this test** The EDA-Q has 26 items that need to be answered. Here are examples of some items: - Obsessively resists and avoid ordinary demands and requests - Complains about illness or physical incapacity when avoiding a request or demand. - Is driven by the need to be in charge. - Finds everyday pressures (e.g., having to go on a school trip/visit the dentist) intolerably stressful. - Tells other children how they should behave, but does not feel these rules apply to him/herself. This test will be handed to someone who can observe the person being assessed for the potential of having PDA. The observer will rate the patient based on what they've observed for the past 6 months. The answer choices for each item are: - Not true - Somewhat true - Mostly true - Very true ### **Is it reliable?** The EDA-Q has been found to have good internal consistency. Various research groups, such as those led by Vincent Egan and Rhianna White, have recorded Cronbach's alpha coefficients between 0.87 and 0.94 (Egan et al., 2018; White et al., 2022) It also has good test-retest reliability and inter-rate reliability when used to assess a small test population that is examined several times, during their life as a child and later on as an adult Egan et al., 2018), but assessing much larger population groups still requires more studies. It also has an inherent limitation of only being a screener. This should not be used as a diagnostic tool. It must be used alongside other tests because your aim in using this is to see if a patient has a high risk of PDA, which is a sign of mental health, developmental, and behavioral disorders.

## **How to use our Pathological Demand Avoidance Test  template** The Extreme Demand Avoidance Questionnaire (EDA-Q) assesses traits associated with PDA. While it's essential to note that the EDA-Q is not an autism assessment or a diagnostic tool, it can provide valuable insights into behaviors indicative of demand avoidance. Here are step-by-step instructions on how to use the EDA-Q assessment: ### **Step 1: Grab a copy of the questionnaire** In this guide, you may open our PDA autism test template in the Carepatron app by clicking the "Use template" button. Alternatively, you may download a non-customizable PDF copy by clicking "Download." ### **Step 2: Review** Before starting, review any accompanying information or instructions provided with the questionnaire. Understand the assessment's purpose and the collected data's intended use. Furthermore, ensure the questionnaire is appropriate for the individual/s being assessed. Please note that this template can be used by observers or by the individuals who are suspected of having PDA. ### **Step 3: Obtain consent** If you are administering the EDA-Q, ensure that you have obtained informed consent from the individuals or their legal guardians, particularly if they are minors. ### **Step 4: Conduct the test** Once you've obtained their consent, choose a quiet and comfortable setting for the assessment to minimize distractions and ensure accurate responses. Afterward, clearly explain the purpose of the questionnaire to the individuals participating. Emphasize that there are no right or wrong answers and that the goal is to gather information about specific behaviors. Depending on the participants' needs, read the questions aloud or provide them with written instructions. Ensure that everyone understands the wording of each question. Give participants sufficient time to consider and respond to each question. This will help ensure thoughtful and accurate answers. The person answering the test only needs to select between 4 answer choices per item. ### **Step 5: Score and analyze** Collect the participant/s' response/s systematically. Ensure that the responses are recorded accurately and attributed to the correct individual. Refer to the scoring guidelines provided with the EDA-Q. Follow the specified instructions for tallying the scores. Once the scores are tallied, interpret the results by the guidelines provided. Keep in mind that the EDA-Q only provides an indication of traits associated with demand avoidance but does not diagnose PDA. Please note that a proper threshold score hasn't been established for this test, but do note that scores greater than 45 indicate a high risk of having PDA. Also, please refer to this scoring guide: - Not true = 0 - Somewhat true = 1 - Mostly true = 2 - Very true = 3 The scores are reversed for Items 14 and 20. ### **Step 6: Proceed with the next steps** If the results of the EDA-Q suggest the presence of traits associated with demand avoidance, it is crucial to have the patient consult with other healthcare professionals for a comprehensive evaluation. Some tests you can conduct after this include the RAADS-R, CAT-Q, and Aspie Quiz.

## **Recommended next steps** After completing the Extreme Demand Avoidance Questionnaire for Adults, understanding the next steps is crucial for individuals seeking further insights into potential PDA traits. ### **Consult a specialist** If you are not a specialist in ASD, seek the guidance of a healthcare professional who specializes in autism spectrum disorder, especially if you suspect your patient might have traits associated with PDA. While the EDA-Q provides valuable insights, only a specialist can provide a formal diagnosis and recommend appropriate coping strategies. ### **Engage with education professionals** Children or adolescents exhibiting PDA behaviors may benefit from working with education professionals who understand and accommodate their unique needs. Collaboration with educators ensures that the child receives appropriate support in school settings, where demands are often frequent and unavoidable. ### **Contact the PDA Society** The PDA Society offers resources, information, and support for individuals, families, and professionals dealing with PDA. Connecting with the PDA Society can provide guidance on managing behaviors, understanding demand avoidance, and accessing additional resources or support networks. Remember, these are general guidelines, and the specific next steps can vary depending on individual circumstances. Additionally, other healthcare professionals may employ various assessments and diagnostic tools to evaluate potential neurodevelopmental conditions comprehensively.

## **References** Egan, V., Linenberg, O., & O’Nions, E. (2018). The measurement of adult pathological demand avoidance traits. Journal of Autism and Developmental Disorders, 49(2), 481–494. https://doi.org/10.1007/s10803-018-3722-7 Miller, C. (2024). Pathological demand avoidance in kids. Child Mind Institute. https://childmind.org/article/pathological-demand-avoidance-in-kids/ O’Nions, E., Christie, P., Gould, J., Viding, E., & Happé, F. (2013). Development of the “Extreme Demand Avoidance Questionnaire” (EDA-Q): Preliminary observations on a trait measure for Pathological Demand Avoidance. Journal of Child Psychology and Psychiatry, 55(7), 758–768. https://doi.org/10.1111/jcpp.12149 O’Nions, E., Gould, J., Christie, P., Gillberg, C., Viding, E., & Happé, F. (2015). Identifying features of “pathological demand avoidance” using the Diagnostic Interview for Social and Communication Disorders (DISCO). European Child & Adolescent Psychiatry, 25(4), 407–419. https://doi.org/10.1007/s00787-015-0740-2 White, R., Livingston, L. A., Taylor, E. C., Close, S. A. D., Shah, P., & Callan, M. J. (2022). Understanding the contributions of trait autism and anxiety to extreme demand avoidance in the adult general population. Journal of Autism and Developmental Disorders, 53(7). https://doi.org/10.1007/s10803-022-05469-3