“Charlie” is an eight-year-old child with autism. Her parents are worried because she often responds to requests with insults, aggression and refusal. Simple demands, such as being asked to get dressed, can trigger an intense need to control the situation, fights and meltdowns.

Charlie’s parents find themselves in a constant cycle of conflict, trying to manage her and their own reactions, often unsuccessfully. Their attempts to provide structure and consequences are met with more resistance.

What’s going on? What makes Charlie’s behaviour – that some are calling “pathological demand avoidance” – different to the defiance most children show their parents or carers from time-to-time?

What is pathological demand avoidance?

British developmental psychologist Elizabeth Newson coined the term “pathological demand avoidance” (commonly shortened to PDA) in the 1980s after studying groups of children in her practice.

A 2021 systematic review noted features of PDA include resistance to everyday requests and strong emotional and behavioural reactions.

Children with PDA might show obsessive behaviour, struggle with persistence, and seek to control situations. They may struggle with attention and impulsivity, alongside motor and coordination difficulties, language delay and a tendency to retreat into role play or fantasy worlds.

PDA is also known as “extreme demand avoidance” and is often described as a subtype of autism. Some people prefer the term persistent drive for autonomy or pervasive drive for autonomy.

What does the evidence say?

Every clinician working with children and families recognises the behavioural profile described by PDA. The challenging question is why these behaviours emerge.

PDA is not currently listed in the two diagnostic manuals used in psychiatry and psychology to diagnose mental health and developmental conditions, the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the World Health Organization’s International Classification of Diseases (ICD-11).

Researchers have reported concerns about the science behind PDA. There are no clear theories or explanations of why or how the profile of symptoms develop, and little inclusion of children or adults with lived experience of PDA symptoms in the studies. Environmental, family or other contextual factors that may contribute to behaviour have not been systematically studied.

A major limitation of existing PDA research and case studies is a lack of consideration of overlapping symptoms with other conditions, such as autism, attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, anxiety disorder, selective mutism and other developmental disorders. Diagnostic labels can have positive and negative consequences and so need to be thoroughly investigated before they are used in practice.

Classifying a “new” condition requires consistency across seven clinical and research aspects: epidemiological data, long-term patient follow-up, family inheritance, laboratory findings, exclusion from other conditions, response to treatment, and distinct predictors of outcome. At this stage, these domains have not been established for PDA. It is not clear whether PDA is different from other formal diagnoses or developmental differences.

Finding the why

Debates over classification don’t relieve distress for a child or those close to them. If a child is “intentionally” engaged in antisocial behaviour, the question is then “why?”

Beneath the behaviour is almost always developmental difference, genuine distress and difficulty coping. A broad and deep understanding of developmental processes is required.

Interestingly, while girls are “under-represented” in autism research, they are equally represented in studies characterising PDA. But if a child’s behaviour is only understood through a “pathologising” or diagnostic lens, there is a risk their agency may be reduced. Underlying experiences of distress, sensory overload, social confusion and feelings of isolation may be missed.

So, what can be done to help?

There are no empirical studies to date regarding PDA treatment strategies or their effectiveness. Clinical advice and case studies suggest strategies that may help include:

• reducing demands
• giving multiple options
• minimising expectations to avoid triggering avoidance
• engaging with interests to support regulation.

Early intervention in the preschool and primary years benefits children with complex developmental differences. Clinical care that involves a range of medical and allied health clinicians and considers the whole person is needed to ensure children and families get the support they need.

It is important to recognise these children often feel as frustrated and helpless as their caregivers. Both find themselves stuck in a repetitive cycle of distress, frustration and lack of progress. A personalised approach can take into account the child’s unique social, sensory and cognitive sensitivities.

In the preschool and early primary years, children have limited ability to manage their impulses or learn techniques for managing their emotions, relationships or environments. Careful watching for potential triggers and then working on timetables and routines, sleep, environments, tasks, and relationships can help.

As children move into later primary school and adolescence, they are more likely to want to influence others and be able to have more self control. As their autonomy and ability to collaborate increases, the problematic behaviours tend to reduce.

Strategies that build self-determination are crucial. They include opportunities for developing confidence, communication and more options to choose from when facing challenges. This therapeutic work with children and families takes time and needs to be revisited at different developmental stages. Support to engage in school and community activities is also needed. Each small step brings more capacity and more effective ways for a child to understand and manage themselves and their worlds.

What about Charlie?

The current scope to explain and manage PDA is limited. Future research must include the voices and views of children and adults with PDA symptoms.

Such emotional and behavioural difficulties are distressing and difficult for children and families. They need compassion and practical help.

For a child like Charlie, this could look like a series of sessions where she and her parents meet with clinicians to explore Charlie’s perspective, experiences and triggers. The family might come to understand that, in addition to autism, Charlie has complex developmental strengths and challenges, anxiety, and some difficulties with adjustment related to stress at home and school. This means Charlie experiences a fight, flight, freeze response that looks like aggression, avoidance or shutting down.

With carefully planned supports at home and school, Charlie’s options can broaden and her distress and avoidance can soften. Outside the clinic room, Charlie and her family can be supported to join an inclusive local community sporting or creative activity. Gradually she can spend more time engaged at home, school and in the community.

Nicole Rinehart, Professor, Child and Adolescent Psychology, Director, Krongold Clinic (Research), Monash University; David Moseley, Senior Research Fellow, Deputy Director (Clinical), Monash Krongold Clinic, Monash University, and Michael Gordon, Associate Professor, Psychiatry, Monash University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

If you walk into a cosmetic surgeon’s office, you probably wouldn’t expect to be asked about your recent break-up or how you cope with stress.

But in Australia, that has been standard practice for nearly three years.

That’s after the Australian Health Practitioner Regulation Agency introduced mandatory mental health screening before cosmetic procedures. This includes cosmetic surgery, like a facelift, and non-surgical procedures including cosmetic injections and laser treatments.

This decision was part of a series of reforms designed to help keep patients safe. But it has also made the Australian cosmetic industry one of the most tightly regulated in the world.

So how effective have these reforms been, almost three years on? And are patients any better off?

Cosmetic medicine is booming in Australia

Each year, Australians spend more than A$1 billion on more than 500,000 cosmetic procedures. That means we spend more money on cosmetic medicine per capita than the United States.

In 2023, more than a third of Australians were considering having cosmetic surgery in the next decade. Interest is particularly strong among young women, with 54% of young Australian women considering cosmetic surgery at some point in their lives. Most people seeking surgery hope these elective procedures will improve their appearance or self-esteem.

After having cosmetic surgery, about 80–90% of patients are satisfied with the results. Many also report feeling better about their appearance up to five years after the procedure. Some studies also show cosmetic surgery improves patients’ mood and quality of life.

However, some patients may regret a cosmetic procedure or feel worse afterwards. This is why identifying vulnerable patients, especially those considering irreversible procedures, is crucial.

So, what’s the link between cosmetic surgery and mental health?

Research shows a patient’s psychological state before any cosmetic procedure affects how they feel after an operation. People with heightened symptoms of psychological distress, such as anxiety and depression, are more likely to be dissatisfied with the results of a cosmetic procedure. They are also more likely to find their recovery challenging and even experience more physical complications after surgery.

Certain psychological conditions have a greater impact on patients’ mental health after surgery. One example is body dysmorphic disorder, where people often obsess over perceived flaws in their appearance. These so-called flaws can be subtle or not apparent to others. As a result, these patients may look to cosmetic surgery as a way to fix their perceived flaws.

A 2022 review of related studies found up to 20% of patients requesting cosmetic procedures had body dysmorphic disorder. And our 2025 study shows about 12% of Australian cosmetic patients either have unrealistic expectations of cosmetic surgery or show symptoms of body dysmorphic disorder or psychological distress.

Many patients with body dysmorphic disorder still feel dissatisfied with their appearance after cosmetic treatment. This is because they often focus on the same perceived flaw or a completely different one. This can negatively impact their mental health and, in some cases, may lead patients to take legal action against surgeons for not delivering the desired result.

The reason for screening

Nearly three years ago, the Australian Health Practitioner Regulation Agency changed its guidelines about cosmetic procedures.

As a result, doctors who perform cosmetic procedures must screen patients for psychological conditions, such as body dysmorphic disorder. They can do this by conducting interviews or using tools such as a written questionnaire.

If doctors identify any concerns, they must refer patients to a psychologist, psychiatrist or GP before proceeding with treatment.

However, a recent national survey suggests the cosmetic industry is not embracing these reforms. This research shows 84% of plastic surgeons referred fewer than 5% of patients. This is far less than our research would indicate have body dysmorphic disorder. About 70% of plastic surgeons interviewed say they would not continue screening if it were not mandatory.

Some surgeons have made their concerns public. In 2024, one group of surgeons even took the Australian Health Practitioner Regulation Agency to court. They sought to overturn the new guidelines or establish other protections for patients.

From a patient’s perspective, mandatory screening may mean they can’t undergo cosmetic surgery. In our 2025 study involving more than 8,000 Australian cosmetic patients, we found people were much more hesitant to report mental health symptoms in a cosmetic clinic, compared to when completing the same questionnaire anonymously for research. This is likely because they felt they needed to “pass” psychological screening tests to receive cosmetic surgery. So, the self-reporting element of current questionnaires is a major limitation.

So, is psychological screening necessary?

The purpose of screening was never to exclude people from cosmetic treatment. Rather, it was designed to help practitioners and patients make informed decisions.

Almost half of people considering cosmetic procedures report mental health concerns. For most, this does not make them unsuitable candidates. But in certain cases, they may benefit from delaying a cosmetic procedure. This would give them time to seek additional psychological support or talk to a practitioner about what they should expect from cosmetic surgery.

Importantly, screening tools should not be used alone. Instead, they should be part of a broader assessment of a patient’s motivations, goals and overall wellbeing. This includes a discussion of how cosmetic surgery may positively or negatively affect their mental health.

But researchers, like ourselves, are working on new screening questionnaires to help surgeons more accurately assess a patient’s mindset and identify any psychological concerns before they have a cosmetic procedure. But we need more research to know if these will improve outcomes for patients and practitioners.

Yes, talking about your mental health with a cosmetic surgeon may feel uncomfortable. But it helps ensure any decision to change how you look comes from a place of stability, not distress.

Correction: this article originally stated examining patients’ mental health before any cosmetic procedure affects how they feel after an operation. This has been amended to say it’s their psychological state rather than the examination of it.

Toni Pikoos, Adjunct Research Fellow, Swinburne University of Technology; Federation University Australia and Ben Buchanan, Adjunct Research Fellow, School of Psychological Sciences, Monash University

This article is republished from The Conversation under a Creative Commons license. Read the original article.