Intolerance of uncertainty underlies demand avoidance behaviours in children

Last updated 4 January 2024

Researchers in Newcastle have conducted one of the first studies to conceptualise and understand the behavioural features of the pathological demand avoidance (PDA)1 profile — a proposed subtype of autism spectrum disorder (ASD) — in children and young people.

In the first part of their study, Lisa Stuart and colleagues used data from an online survey completed by 214 children aged 4-17 years with clinically diagnosed PDA and suspected PDA, to study the relationships between extreme demand avoidance (EDA) behaviours, intolerance of uncertainty (IU), anxiety and ASD. Here, they found that both anxiety and IU significantly predicted EDA behaviours in children with diagnosed or probable PDA. The researchers thus consider that affected children use EDA in an attempt to increase certainty and predictability to alleviate anxiety.

In the second part of their study, the researchers conducted semi-structured interviews with a subsample of the participants to gain descriptive data on the association between PDA and IU. Here, parents described certainty-seeking behaviours, such as repeated questioning or verbal negotiation, or avoidance, in children showing EDA behaviours. By contrast, there were few reports of aggression as a default response to IU. Overall, the strategies used to manage IU included control behaviour, “withdrawal to fantasy” and “meltdown”.

Taken together, Stuart et al. propose that IU is a relevant construct for conceptualising demand avoidance behaviour in children with PDA. Treatment approaches based on anxiety and IU might, therefore, be beneficial for affected children. One such intervention that targets IU in ASD — Coping with Uncertainty in Everyday Situations2 — is currently under further investigation.

Referring to:

Stuart, L., Grahame, V., Honey, E. & Freeston, M. (2019), Intolerance of uncertainty and anxiety as explanatory frameworks for extreme demand avoidance in children and adolescents. Child Adolesc. Ment. Health. doi: 10.111/camh.12336.

See also:


Pathological demand avoidance: a developmental disorder identified by Elizabeth Newson in 20031 that is increasingly recognized as a distinct profile of autism. Affected patients exhibit a need to resist normal, everyday demands made by others most likely in an attempt to manage acute anxiety. Those with PDA might use social skills to manipulate others. Young people with PDA might exhibit sociability, but have a lack of sense of social identity, pride and/or shame. Many also show a labile mood that can quickly change from passive to aggressive, language delay, obsessive behaviours and over-use of role play and pretending.


1 Newson, E. et al.(2003), Pathological demand avoidance syndrome: a necessary distinction within the pervasive developmental disorders. Arch. Dis. Child. 88, 595-600. doi: 10.1136/adc.88.7.595.

2Rodgers, J. et al. (2017), Towards a Treatment for Intolerance of Uncertainty in Young People with Autism Spectrum Disorder: Development of the coping with uncertainty in everyday situations (CUES©) Programme. J. Autism Dev. Disord. 47, 3959–3966. doi: 10.1007/s10803-016-2924-0.


Dr Jessica Edwards
Jessica received her MA in Biological Sciences and her DPhil in Neurobehavioural Genetics from the University of Oxford (Magdalen College). After completing her post-doctoral research, she moved into scientific editing and publishing, first working for Spandidos Publications (London, UK) and then moving to Nature Publishing Group. Jessica is now a freelance editor and science writer, and started writing for “The Bridge” in December 2017.


I read Newson article and have a couple of question regarding commonality of aggression.

If a child displays extreme demand avoidance, but is not physically or verbally aggressive (not be confuse with bossy), would educational approaches shift? Majority of behaviors fit that of 13 year old, but he spoke on time and did not have delays in walking, but was very clumsy. Could ADHD combined with autism, lead to behaviors similar to PDA.

I am wondering if children struggling with demand avoidance, view all demands as masked “criticism”, and do to demand for control, on unconscious level does not recognize parent/teacher authority to criticize them. Therefore, each demand generates anxiety in some and anger in others. Those experiencing anger, lash out aggressively. Those with heightened anxiety become depressed.

Demand “You need to clean your room?”
Transalation: “You are mad at me because I did not do something, I did not know I needed to do. If you are mad at me, you don’t love me.”
Demand “You need to work on missing classwork assignments today?”
Translation “You don’t love me, or I am not worthy, because I am not completing my schoolwork.”

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