It’s Time to Rethink the “Anxiety Drives PDA” Narrative |
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PDA (extreme demand avoidance) isn't just confined to autism; it's present in ADHD, ODD, and other conditions.
PDA and anxiety are correlated, but anxiety might be a byproduct of high conflict, not the driver of PDA.
PDA may be a changeable personality profile: high reactivity, low agreeableness, and low conscientiousness.
Pathological demand avoidance (PDA) was originally described as a subtype of autism in which anxiety is the primary driver of extreme demand avoidance.
Currently, however, PDA is understood to be present among other mental health conditions, such as ADHD, oppositional-defiant disorder, and other externalizing disorders (Egan et al, 2020; Rai et al, 2026).
The “anxiety as the driver of PDA narrative” is often contrasted with the supposedly “anger-driven” demand-avoidant behavior seen in oppositional-defiant disorder (ODD). The distinction has influenced treatment approaches, particularly the rise of low-demand, high-accommodating parenting models marketed as “nervous system–affirming” care (Carlozzi et al., 2025; Ehrlich, 2025).
A closer examination of the scientific literature, however, suggests that this narrative is less secure than commonly assumed. While anxiety is consistently correlated with PDA-type traits, correlation does not establish causation. We know that anxiety and PDA go together, but we do not yet understand the directionality (what causes what) of the association.
Importantly, substantial research demonstrates that children with ADHD and ODD also frequently exhibit elevated rates of anxiety symptoms (Stein et al., 2015). Additionally, anger, irritability, and explosive outbursts—often characteristics of PDA—are also core features of ODD and are commonly observed in children with ADHD (Green et al., 2018; O’Nions et al., 2014).
Taken together, current evidence does not justify conceptualizing PDA as a uniquely anxiety-driven construct. Currently, no research exists that shows anxiety is the cause of PDA.
It is at least as plausible—and perhaps more clinically useful—to view anxiety as an outcome of chronic demand conflict, similar to how it is viewed in ADHD and ODD.
Unpacking ADHD, ODD, and the Myth of “Anger vs. Anxiety”
To emphasize PDA’s distinctiveness, many contrast “anxiety as the driver of PDA” with “anger is the driver of ODD” (Green et al., 2018; O’Nions & Eaton, 2020).
However, the broader literature challenges this dichotomy. Children with ADHD also exhibit markedly elevated rates of anxiety disorders, with comorbidity estimates ranging from 15% to 50% (Stein et al., 2015). Moreover, ODD also frequently co-occurs with anxiety (Martin et al., 2014).
Although it is frequently argued that anxiety drives PDA, I don’t think anyone would try to argue that anxiety is the primary driver of ADHD.
Clinically, oppositional and externalizing behaviors in ADHD and ODD are often embedded within an anxious emotional profile rather than representing “anger-only” phenomena. Instead, many children with ADHD or ODD present with the same mixture of rage, panic, and desperate avoidance of routine demands now labeled as PDA, particularly in families where compliance battles have become deeply entrenched (Thurston et al., 2012).
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An Alternative Hypothesis: Conflict-Driven Anxiety
Given these overlaps, an alternative to the “anxiety drives PDA” narrative is that anxiety frequently emerges as a downstream consequence of chronic, high-conflict demand cycles.
Anxiety is the exhaust, not the engine.
Research on ADHD and ODD consistently demonstrates a two-way (bidirectional) pattern: expectations in a particular situation (“demands”) exceed the child’s regulatory capacity; parents escalate prompts, threats, or accommodations; conflicts become frequent and emotionally intense; and over time, both child and parent develop anticipatory anxiety surrounding everyday requests (Thurston et al., 2012).
There is little reason to assume that children labeled with PDA follow a fundamentally different developmental trajectory. Family and developmental research indicates that coercive cycles and accommodation–avoidance loops increase both oppositional behavior and anxiety across diagnostic categories (Bertelsen et al, 2022; Kitt et al, 2022).
A Nervous System Disability, Really?
PDA is often characterized on social media as a “nervous system disability,” yet currently, no empirical, neuroscientific evidence exists to support this claim.
Perhaps a more clinically useful, less fixed-trait (and less dehumanizing) perspective is that demand-avoidance is a specific personality profile. For example, Egan and colleagues (2019), using the Big Five personality traits test, found that adults with PDA scored high on emotional reactivity (neuroticism) and low on measures of agreeableness and conscientiousness. Fortunately, decades of research have shown that personality traits can change in socially desirable ways over time and with clinical intervention (Roberts & Wood, 2006).
What We Know So Far About Low-Demand Parenting
A core problem with the anxiety-driven model of PDA is that it is the foundational principle that pushes out the low-demand parenting narrative.
The one published study so far on low-demand (high accommodating) parenting for PDA shows it to be largely ineffective in producing any meaningful improvements in PDA-type symptoms or child behavior (Carlozzi et al., 2025).
After completing Casey Ehrlich’s 12-week Paradigm Shift Program, child PDA-type behavior scores (e.g., conduct problems, peer problems, prosocial behavior, total difficulties, and so on) showed only trivial changes. These changes did not reach statistical significance and were clinically meaningless. The only clear statistically significant change reported was small reductions in parent strain, not in child symptoms.
Furthermore, given the small sample, completer‑only analysis (children who did not complete the program were excluded, thereby artificially inflating any purported treatment gains), simple pre/post design, and lack of a comparison group, even these trivial changes are highly vulnerable to regression to the mean, as well as placebo and expectancy effects.
(Note: The original published version of this study included the lack of improvement in child-related scores, but the newer online version of the study now omits these data.)
Why This Matters for Struggling Families
Overemphasizing the “anxiety drives PDA” narrative carries several clinical risks. First, it may encourage excessive accommodation, where every escalation is rebranded as a panic (“fight or flight”) response, prompting parents to continually lower demands. Such patterns can inadvertently reinforce avoidance and restrict the child’s developmental opportunities, paralleling mechanisms known to worsen anxiety (Bertelsen et al, 2022; Kitt et al, 2022).
Second, this perspective diverts attention from well-established mechanisms—such as coercive cycles, inconsistent contingencies, and skill deficits—that sustain oppositionality across diagnostic categories (Thurston et al., 2012).
Third, it also diverts attention away from known, effective treatments for demand-avoidant behavior, such as Parent Management Training, and sends unsuspecting parents down a path of treatments that are scientifically unsound.
From Syndrome to Signal
Rather than elevating PDA to a separate diagnosis based on an as-yet-unproven causal narrative, it may be more clinically productive to interpret extreme demand avoidance as a signal.
Such a signal indicates that a child’s capacities, environmental expectations, and family dynamics are chronically misaligned, and that conflict-laden, anxiety-inducing interactions have become a central aspect of family life.
Addressing these challenges requires systems- and evidence-based interventions rather than the adoption of a new diagnostic label grounded in uncertain etiology coupled with “treatments” that don’t work.
Bertelsen, T.B., Himle, J.A., & Håland Å.T. Bidirectional Relationship Between Family Accommodation and Youth Anxiety During Cognitive-Behavioral Treatment. Child Psychiatry Hum Dev. 2023 Jun;54(3):905-912. doi: 10.1007/s10578-021-01304-5. Epub 2022 Jan 8. PMID: 34997892; PMCID: PMC10140011.
Carlozzi, N. E., Lombard, W. L., Troost, J. P., Graves, C. M., Miner, J. A., Fauser, A. T., & Ehrlich, C. (2025). A comprehensive parent training program for parents of neurodivergent children with pathological demand avoidance: The Paradigm Shift Program pilot study. Pediatric Investigation, 00, 1–9.
Egan, V., Bull, E., & Trundle, G. (2020). Individual differences, ADHD, adult pathological demand avoidance, and delinquency. Research in Developmental Disabilities, 105, 103733. https://doi.org/10.1016/j.ridd.2020.103733
Egan, V., Linenberg, O., & O'Nions, E. The Measurement of Adult Pathological Demand Avoidance Traits. J Autism Dev Disord. 2019 Feb;49(2):481-494. doi: 10.1007/s10803-018-3722-7. PMID: 30140985; PMCID: PMC6373319.
Ehrlich, C. (2025). The PDA lens: A new vision for supporting nervous system disability. Psychotherapy Networker.
Green, J., Absoud, M., Grahame, V., Malik, O., Simonoff, E., Le Couteur, A., & Baird, G. (2018). Pathological demand avoidance: Symptoms but not a syndrome. The Lancet Child & Adolescent Health, 2(6), 455–464.
Kitt, E.R., Lewis, K.M., Galbraith, J., Abend. R., Smith. A.R, Lebowitz, E.R., Pine, D.S., & Gee, D.G. Family accommodation in pediatric anxiety: Relations with avoidance and self-efficacy. Behav Res Ther. 2022 Jul;154:104107. doi: 10.1016/j.brat.2022.104107. Epub 2022 May 13. PMID: 35613517; PMCID: PMC9271364.
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O’Nions, E., Christie, P., Gould, J., Viding, E., & Happé, F. (2014). 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.
O’Nions, E., & Eaton, J. (2020). Extreme/pathological demand avoidance: An overview. Paediatrics and Child Health, 30(7), 411–415.
Rai, A. J., Rishworth, B., Gutierrez, R., & Ludlow, A. K. (2026). Sensory reactivity and intolerance to uncertainty: What characterises demand avoidance behaviours in children and adolescents with pathological demand avoidance? Research in Autism, 131, 202816. https://doi.org/10.1016/j.reia.2026.202816
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Stein, M. A., Kircanski, K., & Gadow, K. D. (2015). Anxiety disorders comorbidity in children and adolescents with attention deficit hyperactivity disorder. Psychiatry Investigation, 12(2), 183–191.
Thurston, I. B., Tsumura, M. H., McLeod, B. D., & Piacentini, J. (2012). Association of anxiety and ODD/CD in children with and without ADHD. Child Psychiatry & Human Development, 43(3), 452–469.
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