Pathological/extreme demand avoidance. What can we do?

Pathological Demand Avoidance (PDA), a profile observed in some autistic individuals, is characterised by increased resistance to everyday demands, often leading to social withdrawal and distress. Despite ongoing debate over its classification and lack of guidance, PDA-like presentations frequently emerge in clinical practice, highlighting the need for tailored intervention strategies. This case study examines an autistic young person who exhibited severe demand avoidance, anxiety, and school refusal. Using a systemic, neurodiversity-affirming approach, we co-constructed a formulation model and intervention plan with his parent during indirect work. We reframed PDA behaviours as adaptive responses to anxiety rather than oppositional defiance. Over time, he increased his engagement with his family and began considering returning to the school. This case underscores the importance of individualised, family-centred interventions in supporting demand-avoidant behaviours. It highlights the role of perceived control in mitigating anxiety. While indirect work limited direct input from a young person, the co-created strategies empowered his family and facilitated meaningful progress.