Article · PDA · For parents
PDA vs. ODD: why telling them apart is harder than it looks
PDA vs. ODD is usually put forth as distinct from each other, but in reality, the research hasn’t meaningfully pursued distinguishing the two. Whether your child was given an ODD diagnosis, or you discovered PDA somewhere in the wild, the label depends a good deal on who is looking.
Dana dreads the mornings. Rushing out the door to school, she’s had to dress her daughter herself, limp as a newborn one minute and fighting her the next. Dana believes her daughter should be able to at least put her shoes on, but that is a battle she learned long ago to forfeit. She’s posted about it in her moms’ group and run it by the pediatrician. Twice now someone has raised the PDA vs. ODD question: pathological demand avoidance on one side and oppositional defiant disorder on the other.
What is the difference between PDA and ODD?
Pathological demand avoidance (PDA), or pervasive drive for autonomy as many autistic advocates prefer, describes a child who resists everyday demands to an extreme degree (Newson et al., 2003), a pattern widely described as anxiety-driven (Johnson & Saunderson, 2023; Stuart et al., 2020) and mostly identified in autistic children (Kildahl et al., 2021; O’Nions et al., 2016). It is not a diagnosis in the DSM-5 or the ICD-11, the manuals clinicians use to make diagnoses (Green et al., 2018). Oppositional defiant disorder is a DSM-5 diagnosis built on three patterns of behavior: an angry or irritable mood, argumentative or defiant behavior, and vindictiveness (American Psychiatric Association, 2013). PDA explains a child’s behavior through what they may be feeling inside, while ODD describes the behavior as an adult sees it.
Sources in the reference list: Green 2018 · Kildahl 2021 · Stuart 2020 · O’Nions 2014b · Bubier & Drabick 2009 · Shalaby 2024 · APA 2013
Anxiety or defiance? The line is blurred.
At the pediatrician’s office, Dana said, “I’ve heard of this thing called PDA. Could what my child is experiencing be that?” The doctor hadn’t heard much about PDA, only that it was associated with autism, and her child was not autistic. Dana told the doctor it seemed like there was a panic or anxiety driving the behaviors. She recalled the time her daughter was supposed to go to a peer’s birthday party. Her daughter had a meltdown about going, and then, when Dana decided to stay home, had another meltdown about missing the party. She was so anxious about Monday, when everyone at school would be talking about it, that she refused to go.
Dana heard a child who could not go, and the doctor heard a child who would not. Clinical guides such as Attwood and Garnett’s draw the same line, describing ODD as driven by defiance and PDA as driven by anxiety (Attwood et al., 2024). But PDA looks like defiance, and defiance, aggression, spite, and vindictiveness from a child who holds almost no power can also be driven by anxiety.
Research has shown that anxiety symptoms and reactive aggression are consistently related in children (Bubier & Drabick, 2009). In a small British study, parents rated children with the PDA label as having antisocial traits that approached those of a conduct-problems group. Those same children scored higher on anxiety and emotional distress than either the autism group or the conduct group (O’Nions et al., 2014b).
The doctor and Dana were describing the same child, and nothing in the behavior told them which label was right. There is no study that has compared children diagnosed with ODD to children identified with PDA directly (Kildahl et al., 2021). No study has shown whether anxiety drives the avoidance, or follows after a period of perceived loss of autonomy. Until research explores this question, the tools we have for distinguishing are the two inadequate.
In records from about fifty US health systems over ten years, Black patients were 35% more likely than white patients to carry an ODD diagnosis and 61% more likely to carry conduct disorder, and 26% less likely to have ADHD diagnosed at all (Shalaby et al., 2024). Research is not untouched by bias. ODD as a diagnosis has existed in the DSM since the 1980s (Ghosh et al., 2017), and never since then has never explored the child’s own account of their behavior outside of questionnaires and measures.
Dana heard a child who could not go, and the doctor heard a child who would not.
Is it PDA or ODD? How to tell
I start by believing the parent. A PDA questionnaire exists (the Extreme Demand Avoidance Questionnaire), but no one has shown that it can separate PDA from ODD (O’Nions et al., 2014a). If you found this page, you may have come here to find the lightbulb moment many parents describe when they learn about PDA (Curtis & Izett, 2025).
When I’m in the room, I ask if the parent suspects that their child might be neurodivergent. Then I see if what looks like “trying to be defiant” can make sense through an anxiety lens. A child struggling with shoes might be overwhelmed by being told what to do all day at school. There may be sensory issues or trouble with planning and starting tasks behind the behavior (Ben-Sasson et al., 2009; Demetriou et al., 2018). Interestingly, since the first observation of the behaviors we now call PDA were made (Newson et al., 2003), it’s been found that children (and potentially, adults) who exhibit PDA behaviors can retreat into role playing or fantasy, as a coping mechanism or escape (Stuart et al., 2020; Johnson & Saunderson, 2023). In clinical practice when expressed in play it tends to be rigid and scripted – “you say this, I’ll say that.” (O’Nions et al., 2016, 2018). In practice, I’ve also seen this behavior as a lens through which to understand and interpret the world.
When it lands like that, it’s the beginning of a journey rather than an answer. One study showed that out of 112 autistic children, seven in ten also met criteria for another condition, often social anxiety or ADHD (Simonoff et al., 2008). I find that parents have already adapted in meaningful ways to support their child (Curtis & Izett, 2025). I look at what’s going well and what attachment between caregiver and child looks like.
Real-life examples of demand avoidance
Dana can’t understand why it’s so hard. Her daughter loves her swim class, her friends, and her swim teacher. When she’s in the pool she seems so happy, but when it’s time to get ready and go, she collapses on the threshold of the front door. She’s wearing her swimsuit under her clothes with her cap already on, face down and screaming that the cap is pulling her hair. She’s screaming that her mom put it on wrong and that she just wants to rip it off! She hates swimming! She hates the cap! She hates everything! Dana tries to comfort her, but she just screams when Dana comes near.
A year ago, Dana would have lost it and said something like, okay, well, if you hate it then you don’t need to go to swim class anymore! She still feels it rising up inside of her, but she tells that part of her to take a seat. She tries to see it from her daughter’s point of view. That cap must be so tight. And she had a fight with a friend at school this morning. And Dana admittedly couldn’t find the cap she usually uses today. Her compassion is sitting in tension with the prospect of another missed swim class.
Dana’s daughter loves her swim class. She didn’t want to miss it. She just couldn’t go. There is nothing to gain from defiance when it gets in the way of the things you love (O’Nions et al., 2018). That’s anxiety, and for parents, living with it can feel like vigilance and isolation. Not many people can understand why Dana’s daughter was dressed and ready and at the door and still couldn’t make it to the pool. As a PDA parent, I’ve been there. As a therapist, it’s given me the tools to help other parents find their own version of that doorway.
So I just let them get away with it?
Getting away with it is the language of the systems the demands came from, not the language of the child. To lower demands means to reevaluate everything you ever assumed about parenthood, about your children, and about life. It means you are actively having to work against the systems within which you live. As a PDA parent myself, nothing has been more radicalizing than lowering demands and standing as an advocate between my family and the systems that want us to show up every day, be on time, be ready to work.
Part of my ability to accommodate them is my own privilege of having a job where I control my schedule. Sometimes it’s not possible, and the further you are from that kind of privilege, the harder this is. Sometimes I have to look within myself and get curious about why it’s important to me that they put their own shoes on. Honestly, we just take them to the car and they put them on during the drive, or I pop them on while they’re still buckled in if I can.
Getting away with it is the language of the systems the demands came from, not the language of the child.
Where parents can start
Dana breathes through it and sits down a few feet away on the front porch from where her daughter is lying. She uses her body to show that it’s okay and they don’t have to rush. Then she says, “Wow, you have had such a tough day today and I put your cap on wrong. Of course you’re upset.” Her daughter stops crying for a moment to look up. Then she starts to cry in agreement. Dana is mindful about releasing the tension in her body. They don’t make it to swim class that day, but the situation doesn’t escalate, and that is a win for them both.
Dana is co-regulating, lending her daughter her calm until she can find her own (Curtis & Izett, 2025). Her daughter’s nervous system still needs her mother’s to find its way back to calm.
We as parents know that we will love our children no matter what they do. But do they know that? Sometimes we are irritated or anxious, we’re tired, it’s been a long day or a long meltdown, and they interpret our irritation and frustration as a demand to do better (O’Nions et al., 2018). Sometimes it feels like no matter how hard you try, they can’t seem to absorb your love.
I’ve been there, and I’ve charted a path through to a place where I feel more equipped when a child is thrashing on the floor. I can let go of the reason why they’re thrashing and see the child in pain. I can say, I’m here, I can get some water, I can triage without expectation. More times than not. That’s the best any of us can do.
If you want company in that work, it’s what I do with parents: helping your own nervous system learn to hold the immensity of feeling our children have.
Sound familiar? Book a free 15-min consult
Dana is a composite of many parents I’ve worked with. No detail here belongs to one family.
References & further reading (17)
Each entry says what it’s for, so you can tell whether it’s worth your click.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). read →The official definition of ODD that clinicians use. Worth a look if your child has been given this diagnosis and you want to see exactly what it requires.
Attwood, T., Hinze, E., & Garnett, M. (2024, July 9). Differentiating pathological demand avoidance in autism from oppositional defiant disorder. Attwood & Garnett Events. read →A clinician’s guide to the standard anxiety-versus-defiance distinction, with “I can’t, not I won’t” as its center. Useful for seeing how most professionals frame the difference, which is the framing this article questions.
Ben-Sasson, A., et al. (2009). A meta-analysis of sensory modulation symptoms in individuals with autism spectrum disorders. Journal of Autism and Developmental Disorders, 39(1), 1–11. read →Fourteen studies showing that autistic children take in sound, touch, and texture differently from other children. For the parent who suspects the sock seam or the swim cap really is the whole story.
Bubier, J. L., & Drabick, D. A. G. (2009). Co-occurring anxiety and disruptive behavior disorders: The roles of anxious symptoms, reactive aggression, and shared risk processes. Clinical Psychology Review, 29(7), 658–669. read →A review of why anxious children and “defiant” children are so often the same children. The research behind the idea that anxiety can come out looking like aggression. Free to read.
Curtis, S. J., & Izett, E. (2025). The experience of mothers of autistic children with a pathological demand avoidance profile: An interpretative phenomenological analysis. Discover Mental Health, 5(1). read →Ten mothers describe what PDA did to their families, the “light-bulb moment” of learning the word, and how giving their child more control helped. If you want to hear from parents who have been where you are, start here. Free to read.
Demetriou, E. A., et al. (2018). Autism spectrum disorders: A meta-analysis of executive function. Molecular Psychiatry, 23(5), 1198–1204. read →Two hundred thirty-five studies on planning, starting, and switching tasks in autistic people. Relevant if “just put your shoes on” never seems to be simple for your child.
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. read →The main scientific case against PDA as a separate condition. Read it if a clinician has told you PDA “isn’t recognized” and you want to understand the argument they’re standing on.
Johnson, M., & Saunderson, H. (2023). Examining the relationship between anxiety and pathological demand avoidance in adults: A mixed methods approach. Frontiers in Education, 8, 1179015. read →One hundred sixty-three adults, thirteen interviewed. Anxiety and trouble with uncertainty still drive the avoidance in adulthood. For the parent reading about their child and recognizing themselves. Free to read.
Kildahl, A. N., Helverschou, S. B., Rysstad, A. L., Wigaard, E., Hellerud, J. M., Ludvigsen, L. B., & Howlin, P. (2021). Pathological demand avoidance in children and adolescents: A systematic review. Autism, 25(8), 2162–2176. read →Reviews every PDA study published to 2021: thirteen in total, mostly autistic children, mostly parent report, and no study following children over time. The honest state of the evidence, in one place. Free to read.
Newson, E., Le Maréchal, K., & David, C. (2003). Pathological demand avoidance syndrome: A necessary distinction within the pervasive developmental disorders. Archives of Disease in Childhood, 88(7), 595–600. read →The paper that named PDA, from the psychologist who first described these children in the 1980s. Where the whole conversation started, and still the clearest description of what parents see.
O’Nions, E., Christie, P., Gould, J., Viding, E., & Happé, F. (2014a). 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. read →The questionnaire used to screen for PDA traits, and its authors’ own caution that it hasn’t been shown to separate PDA from other behavior problems.
O’Nions, E., Viding, E., Greven, C. U., Ronald, A., & Happé, F. (2014b). Pathological demand avoidance: Exploring the behavioural profile. Autism, 18(5), 538–544. read →The first study to compare PDA children with autistic children and children with conduct problems. The PDA children looked nearly as antisocial as the conduct group and were the most anxious of all three. Free to read.
O’Nions, E., Gould, J., Christie, P., Gillberg, C., Viding, E., & Happé, F. (2016). Identifying features of ‘pathological demand avoidance’ using the Diagnostic Interview for Social and Communication Disorders (DISCO). European Child & Adolescent Psychiatry, 25(4), 407–419. read →Clinic records of 153 children assessed for autism, with the PDA features pulled out. Includes the finding that these children’s pretend play was mostly rigid and controlled rather than free. Free to read.
O’Nions, E., Viding, E., Floyd, C., Quinlan, E., Pidgeon, C., Gould, J., & Happé, F. (2018). Dimensions of difficulty in children reported to have an autism spectrum diagnosis and features of extreme/’pathological’ demand avoidance. Child and Adolescent Mental Health, 23(3), 220–227. read →Parents of 26 PDA children describe what the avoidance looks like at home, including children making it impossible for themselves to do things they wanted to do. Likely to feel very familiar. Free to read.
Shalaby, N., Sengupta, S., & Williams, J. B. (2024). Large-scale analysis reveals racial disparities in the prevalence of ADHD and conduct disorders. Scientific Reports, 14. read →Records from about fifty US health systems over ten years. Black patients were 35% more likely to carry an ODD diagnosis and 61% more likely to carry conduct disorder, and 26% less likely to have ADHD diagnosed. Relevant if you are wondering who gets which label.
Simonoff, E., Pickles, A., Charman, T., Chandler, S., Loucas, T., & Baird, G. (2008). Psychiatric disorders in children with autism spectrum disorders: Prevalence, comorbidity, and associated factors in a population-derived sample. Journal of the American Academy of Child & Adolescent Psychiatry, 47(8), 921–929. read →One hundred twelve autistic children aged 10 to 14; seven in ten met criteria for at least one other condition, most often social anxiety, ADHD, or ODD. Relevant if your child has more than one diagnosis, or you suspect they should.
Stuart, L., Grahame, V., Honey, E., & Freeston, M. (2020). Intolerance of uncertainty and anxiety as explanatory frameworks for extreme demand avoidance in children and adolescents. Child and Adolescent Mental Health, 25(2), 59–67. read →Two hundred fourteen families; the children’s need for certainty predicted their demand avoidance, and anxiety explained the meltdowns. The study behind “the avoidance is about control and uncertainty, not defiance.”
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