One of the questions I hear often is, "what is the difference between Oppositional Defiance Disorder (ODD) and Pathological Demand Avoidance (PDA)". This question often comes from parents who are trying to figure out what is happening for their child when they are seeing them struggle to an extreme degree. These parents are struggling to cope and to understand and are desperately researching oppositional or defiant behaviour, or they have reached out for support and a professional has suggested to them that their child exhibits signs of ODD.
Why are there so many letters? What in the hell is the difference between being oppositional and being demand avoidant? Is one worse than the other? The PDA description sounds just like my child but they aren't autistic, are they, wait, are they?
I get it, I have been right there...
Before I get into the similarities and differences, I want to give you a brief description of each so that we know where we are. I will be skimming the surface but don't worry, I will include links to more information:
Oppositional defiance disorder
- Often loses temper
- Is often touchy or easily annoyed
- Is often angry and resentful
- Often argues with adults
- Often actively defies or refuses to comply with requests from authority figures or with rules
- Often deliberately annoys others
- Often blames others for his mistakes or misbehavior
- Has been spiteful or vindictive at least twice within the past 6 months
In order to be diagnosed with ODD a child must have had a pattern of behaviour problems lasting at least six months and involving at least one individual who is not a sibling.
RISK FACTORS - CAUSE - UNDERLYING ISSUES
It is thought to be "caused" by combining factors, like with mental health conditions and personality disorders. This means there will be a hereditary pre-disposition to mental health issues and then environmental factors play a major part. The "risk factors" are thought to include one or more of the following:
- a “harsh” or inconsistent parenting style
- parental mental health problems such as depression and substance misuse
- adverse childhood experiences (abuse, parental loss, parental breakup etc)
- consistent criticism in one or more setting
- the presence of other mental health problems
- Unrecognised, untreated or mis-managed neurodivergences (e.g. ADHD, Autism)
Pathological demand avoidance
- Resisting and avoiding demands from others, themselves and the demands that are implicitly expected (every day things)
- Needing to be in control
- Using social strategies to avoid and resist demands and keep control
- Lability of mood (mood changes quickly and dramatically between extremes)
- Taking great amounts of comfort from internal role play and fantasy (and can use this to hide their difficulties at times)
- Is social in nature but struggles to maintain social relationships
- Can be obsessive in their interests and become obsessed with people
- Show characteristics of other neurodivergences including sensory processing, executive function and emotional regulation differences.
In meltdown, a PDA child can be extremely aggressive, verbally abusive and violent. Some PDAers never display this behaviour, and channel their extreme anxiety inwards.
RISK FACTORS - CAUSE - UNDERLYING ISSUES
HOW THEY ARE SIMILAR AND HOW THEY ARE DIFFERENT
THE DIFFERENCE IN THE REASON FOR THE BEHAVIOUR
For children with ODD, their behaviour is understood to originate from a persistent and pervasive state of negative thinking and emotions, that stems from extremely difficult experiences or a persistent environment of negativity, either at home or at school, this can trigger a negative state of mind as the "norm" for them. For instance, research shows that ADHD children receive considerably more criticism than neurotypical children. The ODD child is triggered by the perceived source of negativity; authority. This leads to emotional fragility, persistent anger and annoyance, low tolerance for people, and frequent confrontations and altercations with people in positions of authority. ODD is a childhood behaviour profile which, if it continues, can become an adult conduct disorder.
For the PDAer, the behaviour is understood to be a difference in wiring and chemistry in the brain that (amongst other things) triggers a threat response when the person is faced with demands. I actually believe that it would be more accurate to describe that the response is triggered when there is any perceived threat to their autonomy, but that is a matter for another day. The key thing is that demands (all kinds) will cause the PDAer to go into fight (aggression and violence), flight (avoidance to extreme degrees) or freeze (shutdown).
DIFFERENCES IN SOCIAL INTERACTION
DIFFERENCES IN MOOD PATTERNS
A child with ODD will have fairly consistent negative emotions to lesser or greater degrees at a given time. The PDAer is more likely to switch moods inexplicably and experience fleeting emotions where they may suddenly flip, and then are back to being ok reasonably quickly. The PDAer can swear at, scream at and threaten the people they love to avoid a demand, and then when the demand is removed, as long as meltdown hasn't happened, be suddenly calm and affectionate. This is not manipulation but genuine terror occurring and subsiding. The ODD child will remain angry and resentful for longer.
Equally the PDAer is likely to feel full of remorse after a meltdown for the behaviour displayed, as a meltdown in its nature is a total loss of control.
The ODD child is less likely to feel remorse and is more likely to remain in control of their actions, though not always.
THE DIFFERENCE BETWEEN DEFIANCE, DEMAND AVOIDANCE AND PATHOLOGICAL DEMAND AVOIDANCE?
So what makes the defiance different? Here is where it is super tricky. All human beings can be defiant and all human beings can be demand avoidant. This means both children can display both behaviours. However this also makes it easy to understand.
We have all felt like we do not want to do as we are told by the person in front of us because we feel angry inside ourselves, or angry with them, or angry about having to do the task. When we refuse on these grounds, we are being defiant and our refusal is driven by anger. In these cases we outright refuse or we become obviously and outwardly angry.
We have also all felt like we do not want to do something or are unable to do something for other reasons that are not because we are angry or annoyed at being asked. It could be from exhaustion, a lack of motivation or from apprehension at the complexity or length of the task. Ever left an essay to the last minute? This apprehension can sometimes be more extreme and be better characterised as anxiety. Avoiding doings things because the thing causes us anxiety is typical. In some people, including those with mental health difficulties and neurodivergences, certain tasks or activities (like making phone calls, going outdoors, social gatherings or complicated organisational tasks) are anxiety inducing. These people will go to greater lengths to avoid these tasks than others. All of this is considered demand avoidance and it is driven by either a lack of motivation, lack of executive function or by stimulus that causes anxiety.
The reason that PDA is described using the P word is because the avoidance of demand in the PDAer is abnormal or atypical and to an extreme and pervasive degree. The PDAer does not only avoid demands that cause them anxiety. The PDAer's anxiety is actually caused by the presence of demand. The telling, requesting, reminding, begging, or even gently expecting of the PDAer all cause utter panic, even when they expect things of themselves.
I keep struggling to describe the feeling to people but I will give it a go: I am a black belt in Taekwondo. I love it and find classes really help my mental health. I really enjoy it. However, I battle myself every time it is Taekwondo day, arguing in my brain with my PDA. My threat system is telling me that everyone expects me to go, including me, and I need to resist at all costs. I have to fight it with everything I have, because I want to go. If anyone reminds me to get ready, it feels like they just put a brick wall up in front of me, and my brain screams STOP. DANGER. FIGHT. RUN.
As you can see from this description this can be a long and slow internal struggle, which can suddenly become unmanageable. I am an adult so I mostly fight with myself but when pushed I will use all kinds of strategies to avoid demand, including, distraction, procrastination, incapacitating myself, making excuses, and on and on until it’s all too much. For me meltdowns are sobbing for hours or visible panic attacks and sometimes it is more shutdown.
A quick summary
PAHTOLOGICAL DEMAND AVOIDANCE
-Lability of mood
-Perceives demand as a threat
-Avoids multiple types of demand including things they want to do and every day activities
-Uses social strategies to avoid demands to increasing degrees before meltdown
-Shows much remorse after extreme avoidant behaviour and meltdown
-Present from birth (not always obvious)
-Will display extreme anger in fight mode
-Will have executive function, sensory and emotional regulation differences.
OPPOSITIONAL DEFIANCE DISORDER
-Negative cognitive and emotional pattern
-Persistent anger and annoyance
-Perceives authority as a threat
-Avoids things they don't want to do, things they are afraid of doing, or requests that make them angry
-Uses refusal and aggression to defy authority figures
-Shows less or no remorse for defiant behaviour
-Triggered by difficult life situations
-Struggles to control anger and annoyance
-Sensory & executive function differences only if neurodivergence is also present
QUICK TEST... (THIS IS HOW YOU TELL THE DIFFERENCE)
Now that we can see the pattern a little clearer, there is one way that can be potentially very helpful to observe which you may be dealing with. The reaction of the child to rewards and imposed consequences will be a good indicator. The child with ODD will often respond well to being offered increased external motivation to do something. If they can see the point in doing the task, even if they don't really want to, they will often comply. Therefore, if you want an ODD child to tidy their room, for example, offering them a new lego set or telling them they won't be able to go out on their bike tomorrow, will increase the chance that they will tidy their room. Now I have researched motivation a great deal and I want to tell you that this approach to parenting whilst widely acceptable is unhelpful in the long term. That is also a topic for another day. In the short-term though, with an ODD child, it will get the result you want in most cases.
Now, try offering the same thing to the PDAer who is refusing to tidy their room and watch meltdown occur. The looming threat or even the reward hanging over them will not motivate them. It will simply increase their anxiety to a point they cannot control. All you have done is increased the demand of that activity by a factor of 10 (or more depending on the weight of the threat or value of the reward).
A NOTE ABOUT ANXIETY AND STRUGGLING CHILDREN
Reading this may make you feel as though ODD is a profile of a traditionally considered "naughty" child, whereas PDA is not. This is not the case. Firstly, I think the label naughty (or any other derivative of this) is extremely loaded and unhelpful at all times. Children show positive behaviour when they can. If they are displaying difficult behaviour, they are struggling. The evidence is very clear that regardless of the difficulties behind the behaviour, both the ODD and the PDA child are struggling and need compassion and loving care.
Why does it matter?
The really important thing is that how this compassionate parenting is approached is likely to look pretty different depending on what is happening for your child.
Very simply, the ODD child will need strong boundaries and limits, enforced with high levels of empathy and compassion, appropriate positive reinforcement and a great deal of consistency and connection. Demands do not necessarily need to be reduced and communication can be direct as long as the child is being handled gently.
The PDA child needs a flexible approach, lots of autonomy, a low or no demand environment, collaborative and problem solving techniques without extrinsic reward, with very careful management of communication and praise, and an individual approach to their sensory needs.
Both children need to have adults around them that really understand and have empathy for their individual situation. Both children can be extremely challenging to live with and to raise. Both children need us to manage our own issues so that we can do the best for them. Whichever you are dealing with, I know you are doing the very best you can because you have taken the time to read this. Thank you from me and thank you from the child who may never find the words of gratitude for you. Keep learning and trying to see the world through their eyes.
Emily Wilding Fackrell
If you have a comment to make on what I have written or you have a simple question, please comment below. If this has brought up lots of questions, wonderings about your child or yourself, or you have had an emotional reaction to reading this, please drop me a message to discuss it further. I also have a list of services that I offer for anyone wanting personalised education or support.