High Stress, Ineffective Interventions Worsen PDA: New Report
The first-ever survey exploring the impact of pathological demand avoidance in kids and adults finds high rates of school refusal, family estrangement, comorbidities, and unhelpful interventions.
February 23, 2026
Chronic stress, high rates of co-occurring conditions, and unhelpful school and clinical interventions are common among individuals living with pathological demand avoidance (PDA), according to the first-ever comprehensive survey exploring the lived experience of PDA.1 The survey found that failure to meet the needs of children and adults with PDA results in difficulties at school, at work, and in relationships, often leading to family breakdown and estrangement, school refusal, underemployment, and mental health struggles.
The 2,000 survey respondents comprised three groups: caregivers of children and teens with PDA; caregivers of adults with PDA; and adults with PDA themselves. Though the ripple effects of PDA on education, work, and family life varied across these groups, the core characteristic of PDA remained strikingly stable, with the “resistance to being told what to do” emerging as the most commonly reported trait across all groups.
For children, school was one of the realms most dramatically impacted by PDA; 88% of children with PDA experienced school avoidance or refusal at some point, and 40% struggled to attend school most days. While 70% of children with PDA had IEPs/ 504 Plans, only 17% of caregivers found these to be “very helpful.”
For adults with PDA, family life and mental health were major areas of struggle, with almost a quarter of adults with PDA, and/or their caregivers, reporting family estrangement. Nearly 60% of adults with PDA reported experiencing thoughts of suicide.
Understanding PDA
In a recent ADDitude webinar, “Don’t Tell Me What to Do: Pathological Demand Avoidance in Neurodivergent Kids,” Diane Gould, LCSW, founder and executive director of PDA North America, discussed the degree to which PDA is misunderstood. She explained that core features for children include:
- Resisting and avoiding ordinary demands of life
- Difficulty complying with the requests or rules of others
- Difficulty making themselves do the things they want to do
- A fundamental need for control
Because of this difficulty with compliance, Gould said: “PDA individuals are so often undiagnosed or misdiagnosed. Adults and teens are often misdiagnosed as having bipolar or borderline personality disorder. Children are misdiagnosed with oppositional defiant disorder or conduct disorder.”
As the report’s authors write: “PDA is not about ‘refusing to cooperate,’ but about the need for autonomy, safety and survival.”
A Dearth of Effective Interventions
This lack of awareness about PDA has resulted in a notable dearth of effective interventions.
“Across surveys, no single intervention was consistently rated as helpful, highlighting the need for better tailored approaches for PDA individuals,” write the report’s authors. Moreover, the report found that encounters with affirming, informed providers were rare, and that caregivers and adults with PDA infrequently received helpful, validating guidance. According to survey results:
- The most helpful interventions were medication management and occupational therapy
- The least helpful interventions were Applied Behavior Analysis (ABA) and emergency room visit
- 94% of caregivers reported that punishment can worsen behaviors
“Probably the hardest thing for parents to talk about was how hard they tried to follow all the advice that they were given from therapists, psychiatrists, pediatricians, teachers, and even parenting books,” Gould said. “But those strategies didn’t work, and often made things worse.”
The report’s authors explain that PDA-informed care involves “respecting autonomy at any age, reducing pressure and unnecessary demands, planning for sensory needs, and using relationship-based, responsive approaches.”
Common Co-Occurring Conditions
PDA commonly co-occurs with neuropsychiatric conditions, most frequently autism, ADHD, or both.
| Co-occurring condition | Prevalence reported by caregivers of children | Prevalence reported by caregivers of adults | Prevalence reported by adults |
| Autism | 75% | 76% | 40% |
| ADHD | 70% | 70% | 71% |
| Anxiety Disorder | 51% | 66% | 61% |
The Impact of PDA on Education
Chronic, severe difficulty attending school is the norm for children and teens with PDA. The survey revealed the following:
As Reported by Caregivers of Kids
- 88% of children with PDA experienced school avoidance or refusal at some point
- 4 in 10 children struggled to attend school most days
- 1 in 5 reported suspensions
- 1 in 10 was not currently accessing any education
- 70% had an IEP or 504 Plan
- Just 1 in 6 found their IEP/ 504 Plan to be “very or extremely helpful”
Despite these consistent difficulties, adults with PDA overwhelmingly report having received a high school diploma, with the majority also earning a four-year college degree.
As Reported by Adults
- 96% completed an education equivalent to a high school diploma
- 83% had a four-year college degree<
The Impact of PDA on Work
While adults with PDA struggle to attend work regularly, and experience episodes of under- or unemployment, the vast majority are employed. A high percentage of PDA adults are self-employed, which helps alleviate work-based challenges:
As Reported by Caregivers of Adults
- Two-thirds reported employment at some point
- More than half reported periods of unemployment or underemployment
As Reported by Adults
- 97% of adults reported employment at some point
- Among these, 55% had a history of self-employment
- 80% reported challenges with workplace attendance
- Two-thirds reported periods of unemployment or underemployment
The Impact of PDA on Family
Family life is strained for those with PDA, whether adults or children. This finding is vividly illustrated by Lisa McKay’s experience, as described in the ADDitude article, A Parent’s Guide to Navigating Pathological Demand Avoidance.
“During his early years, Max would frequently refuse to do what was asked of him and insist everything be done his way,” McKay writes. “He would inexplicably melt down or erupt in anger over seemingly minor issues.”
The survey measured the extent to which these areas of life are affected by PDA:
| Life Impacts | Prevalence, reported by caregivers of children | Prevalence, reported by caregivers of adults | Prevalence, reported by adults |
| Family breakdown | 16% | 32% | 20% |
| Family estrangement | 6% | 23% | 23% |
| Contact with law enforcement | 4% | 16% | 8% |
As families navigate these turbulent, murky waters, validation and accurate information about what works for PDA — and what doesn’t — is key.
“Commonly suggested behavioral strategies for neurodivergent children — from setting clear rules to using checklists, visual timers, and liberally doling out praise — didn’t help.” McKay says. “In fact, all they seemed to do was set up further power struggles where everyone lost.”
McKay’s experience is echoed over and over again by the findings of the survey. “This report makes clear that the challenges families face are not due to a lack of effort or care, but to systems that are not designed with PDA in mind,” said Ruth Hevelone, PDA North America’s director of Strategic Growth & Marketing. “When supports are aligned with how PDA is actually experienced, outcomes can change dramatically.”
Research Team Lead for the PDA report, Michele Kleinmann, added: “We hope this data helps shift conversations away from ‘fixing behavior’ and toward building environments where PDA individuals can feel safe, understood, and supported.”
