What is Pathological Demand Avoidance (PDA)?

“Can’t…not won’t”

Pathological demand avoidance is a profile (pattern of behaviours) rather than a diagnosis. It is also sometimes referred to as ‘Persistent Demand for Autonomy’ - some people prefer this term as it emphasises the child’s strong need for control and self-direction.

Some Autistic individuals have a PDA profile, but not everyone with a PDA profile is Autistic. Autistic children may experience demand avoidance behaviours, but when this becomes persistent and more significant, a PDA explanation may be helpful.

The most noticeable characteristic of PDA is a determined avoidance of the ‘common’ demands of life, including things the person usually enjoys doing. It is important to understand that PDA is not just about demand avoidance and that not all Autistic children have PDA. The profile is not always well understood.

When children feel overwhelmed by what’s happening around them e.g. being repeatedly asked to use the toilet or take unpleasant medication - they may display demand-avoidant behaviours as a way of coping and regaining a sense of control.

How does PDA affect children’s toileting?

With PDA, a child may avoid everyday demands such as going for a wee simply because it feels like a demand. When a person feels the expectation of the demand or task, this can lead to anxiety due to a feeling of losing control. They often can’t, not won’t.

At times, they may be unable to meet the demand because their nervous system is now in its sympathetic state. This is when our body activates the "fight, flight, freeze, fawn and/or flop” response. The individual may be feeling very anxious and/or frightened. This is very different to someone just not wanting to do the thing they need to. Demands can originate from within (feeling the need to wee) or come from outside sources (a parent saying "it's toilet time") and both can trigger a response in the nervous system . 

A PDA profile is a spectrum and is unique to each child. The behaviours exhibited may vary in different situations. When children experience stress, these challenges may be heightened. PDA is not a matter of choice.

Children may display a range of behaviours to avoid doing what adults ask. There are strategies to respond to these behaviours, and they may be useful for children who do not comply, even if they don’t have a diagnosis of PDA.

A child with his head in his hands looking sad.

How might PDA present in children?

Children may:

Withdraw, refuse or shutdown to avoid demands.
Try more socially accepted means to avoid demands, such as distraction or procrastination.
Appear to enjoy social interaction but may lack depth in understanding.
Show a more instinctive response such as fight/flight/freeze.
Struggle with the demand of things they would like to do, as well as things they do not want to do.
Not be able to always do what adults want them to; this is can’t, not won’t, due to the anxiety they feel from the demand.
Resist daily tasks.
Experience high levels of anxiety and a need for control.
Demonstrate impulsive behaviours and mood swings.

Toileting issues

Feeling the need to wee and poo is a demand from inside the body. These demands can cause anxiety making it challenging for a child to relax and let the wee and poo out. Prompts and requests can add to these feelings.

Children may resist letting the wee and poo out of their body when they feel a lack of control in other areas of their lives.

Avoiding visits to the toilet to wee and poo can lead to constipation and urinary tract infections. They may also be unwilling to take necessary medications such as laxatives and antibiotics, used to treat such conditions.

A child with a PDA profile may also experience sensory challenges, including problems with interoception, which is our ability to recognise our body’s internal signals. Altered interoceptive awareness may make it difficult to recognise when they need to go for a wee or poo. Some children may feel overwhelmed, and others may struggle to distinguish between the signals; some may not feel the signals at all.

What are the typical behaviours related to toileting for a child with a PDA profile?

Refusal to go to the toilet – daily battles to get the child into the bathroom.

Withholding poo or withholding wee

Becoming distressed when going into toilets/bathrooms.

Refusing to see a doctor or other healthcare professional.

Refusing to talk about wee, poo or toileting.

An empty toilet role with one sheet left saying 'Don't panic!'

How to help with toileting

Record your child’s bladder and bowel habits.

Monitoring your child’s wees, poos and drinks will help you to spot when they are withholding and help to identify problems such as constipation and UTI. If you spot wee problems, then read Advice for children with daytime bladder problems - ERIC'

You might find the Drinks, Wees and Poos Diary helpful. If you spot poo problems, then read the Advice for children with constipation.

Strategies to help manage anxiety

Anxiety can be expressed in many ways including repetitive behaviours, shouting, lashing out, withdrawing or masking.
Understanding can help to ease anxieties. Teach your child about their digestive and urinary system - even young children are often interested in how their body works! You can speak about it whilst eating dinner or having a drink. Watch videos together, trace around your child on a large piece of paper, or on the driveway with chalk, and fill in the organs while you talk about how they work.
Give your child more choice around their toilet routine - what time will they go? Who will come with them? What will they bring to the toilet? Will they use the potty or toilet? Which underwear do they choose?
Support with visuals to ensure you and others caring for your child are consistent with language, and to help prepare your child for what is coming next.
Understand that children will be able to manage higher demands when they are regulated and need lower demands when they are not.
Try to reduce your child’s anxiety with some relaxation time, quiet time, yoga and dance.
Be aware of your own anxiety and model how to manage this – take deep breaths and think how you move your body. You might like to try mindfulness together.

Techniques to help manage the behaviours

Observe and analyse behaviours before deciding a solution.

Understanding your child’s sensory and interoceptive needs may help to understand their behaviour.

Sensory profiling may be useful. A Children’s Occupational Therapist (OT) may be able to advise.

Acknowledge that an individual approach will be required to support your child’s needs.

Find a professional who is able to build a good relationship with the child (they do not need to be a PDA expert but should have a curiosity to learn and understand). Work together to devise strategies which support you and your child.

Be flexible and patient – finding creative and innovative ways may take time.

Other things that may help

Ensure a low demand approach. Consider demands that can be dropped or postponed. Be consistent with non-negotiables.
Take a strengths-based view, and notice what does go well - those moments when your child manages or is more flexible can tell us a lot about what helps them feel safe and in control.
When communicating with your child support their understanding by using:
- clear concise language
- signs, objects or visuals
- small steps, breaking tasks down.
Be cautious with rewards as these can add an extra demand.
Avoid questions as these demand answers.
Make suggestions and give information e.g. “I wonder if there is any poo ready", I’m happy to help” or “I wonder why you’re dancing around like that”.
Careful wording can make a big difference – look at Language table below for ideas.
Use indirect suggestions e.g. physical prompts, pictures, magic code words, relevant books and videos.
Toileting may take longer than you expect, so allow plenty of time. Being relaxed will help.
Try using a toy or puppet to talk about wee and poo.
Some children may like reminders such as alarms or vibrating watches.
Talk about your own wees and poos. Encourage openness within the family.

Language ideas – courtesy of Dr Cleo Williamson

Neutral Choice-based language	Reassuring and Low-Pressure Phrases	Everyday Routine Language
These phrases give choice without pressure	These normalise difficulties and take away any sense of failure.	Embedding toileting naturally into routines helps it feel less like a demand.
“The bathroom’s open if you want it.”	“There’s no rush, you can try when you’re ready.”	“We’re about to have lunch, shall we see if the bathroom’s free?”
“Would you like to go now or later?”	“It’s okay if it doesn’t happen right now.”	“Let’s wash our hands and check if your body wants the toilet.”
“I’m going to the toilet, you can come if you’d like.”	“Sometimes it takes a few tries, that’s fine.”	“Before we get cosy for a story, maybe check if your body’s comfy.”
“You can decide if now’s a good time for your body.”	“You’re the boss of your body.”	“When we brush our teeth, we can also see if your body’s ready.”
“Your body will let you know when it’s ready.”	“Let’s make sure you feel comfy first.”
When Accidents Happen	Indirect / Playful Language	Externalising Language
Stay calm and kind. This helps your child stay regulated and maintain trust.	Gentle humour and imagination can make toileting feel lighter and less demanding.
“That’s okay, accidents happen.”	“I wonder if your tummy feels full or empty.”	“I think your tummy’s whispering that it might want a wee.”
“Your body’s still learning, it’s no big deal.”	“Let’s give our bodies a little break.”	“Your poo might be ready to go on its big trip to Poo Land!”
“Let’s get you clean and comfy again.”	“Even superheroes need toilet breaks!”	“Your teddy looks like they might need the potty — do you think your body does too?”
“Everyone has tricky days, it’s okay.”	“Your teddy might need the potty, do you think you do too?”

Further help

Care for yourself too – in order to support a child, we all need to find ways to take care of ourselves. A support group where others understand may be helpful.

PDA Society

Demand avoidance

Note: This resource is the result of a collaboration between the ERIC team and ERIC trainers; Dr Cleo Williamson, Psychologist and Tabitha Poole, Occupational Therapist.

If you have any questions or worries about your child’s continence seek advice from your 0-19 service or GP who can support or signpost you to the correct services.