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Is the concept of Demand Avoidance Phenomena (Pathological Demand Avoidance) real or mythical?



This is an updated presentation I gave to the Disability Research Forum at Sheffield Hallam University on 12th of December 2019. I have had this peer reviewed, but it was rejected mainly due to my writing style in the piece. I am planning on adapting it into a book chapter. This is a simple document analysis to conduct, please do replicate if you have a spare few hours. I would be interested if your results diverged significantly from myself. The updates to the powerpoint are mainly adding relevant material from more recent observations, especially around the diagnostic tools and proposed changes to DAP diagnostic criteria. Abstract (from rejected paper). The term Pathological Demand Avoidance (PDA) is increasingly associated with autistic persons, yet there is little consensus over what it means. PDA is often conceptualised as falling within the Broader Autism Phenotype (BAP). The autistic scholar Nick Chown (2019), investigating the BAP and Autistic traits constructs conducted a content analysis of their tools, to assess if any feature is specific (only located to each construct). His research suggests no characteristic is unique to either BAP or Autistic traits. I replicated Nick Chown’s study on 63 questions, drawn from the 3 validated tools for PDA. I assessed each item for if it portrays a feature that is unique to either autism or PDA, and then justified the answer. I found that no features assessed by the 63 questions are solely located in autism or PDA, instead these features are: (1); typically found in persons who are either highly distressed or the result of trauma; (2) acts any individuals utilises to assert their self-agency; (3) a minority of features are found in criminal activities. These results indicate that the notion PDA traits are an autism subtype is a reified construct and instead, PDA traits are more representative of the entire human population.
Is DAP real or mythical? 1
Is the concept of Demand Avoidance
Phenomena (Pathological Demand
Avoidance) real or mythical?
Richard Woods.
12th of December 2019.
Is DAP real or mythical? 2
My Bias.
1) The speaker meets its proposed profile, but
that does not mean much.
2) Demand Avoidance Phenomena (DAP) Sceptical
that DAP is an autism subtype or a syndrome.
3) DAP can be viewed as a stand alone construct.
4) Significantly more compelling research in both
quantity and quality.
Is DAP real or mythical? 3
1) Main DAP discourse.
2) DAP diagnostic traits & its limitations.
3) Screening/ Diagnostic tools.
4) Discussion.
5) Limitations.
Is DAP real or mythical? 4
Main DAP Discourse.
1) Called Pathological Demand Avoidance or
Extreme Demand Avoidance.
2) A distinct syndrome with unique strategies.
3) An autism subtype/ Pervasive Developmental
4) DAP is controversial (Falk 2019; Fidler &
Christie 2019; Green et al 2018b; Kaushik et al
2015; O’Nions et al 2014a; O’Nions et al
5) Dichotomy “for” & “against” sides.
Is DAP real or mythical? 5
A Pathological Demand for name change.
1) There is substantial debate over its name
(Woods 2019a).
2) Demand to change its name (Eaton 2018a;
Gillberg 2014; Kay 2019; Milton 2017; Newson
et al 2003; Reilly et al 2014; Sanchez 2018;
Woods 2019b).
3) Demand Avoidance Phenomena.
Is DAP real or mythical? 6
Autism + DAP Traits criteria.
1) Comfortable in role play & pretend.
2) Continues to resist & avoid ordinary demands
of life.
3) Demand avoidance can use social strategies.
4) Lability of mood & impulsive.
5) Obsessive behaviour, often focused on other
6) Surface sociability, but apparent lack of sense
of social identity, pride, or shame (Fidler
2019; Green et al 2018a; Thompson 2019).
Is DAP real or mythical? 7
Non-essential criteria.
1) Delayed Speech Development.
2) Neurological Involvement.
3) Passive early history (Newson et al 2003).
4) Sensory differences (Eaton et al 2018).
Is DAP real or mythical? 8
Profile limitations.
1) No good quality research suggesting what
diagnostic traits are compulsory or optional.
2) DAP criteria is unstable (Eaton 2018a; O’Nions
et al 2014a; 2016).
3) 4 separate profiles, see Eaton et al (2018);
Green et al (2018a); Newson et al (2003);
Woods (2019b)
4) No agreement over diagnostic criteria & are
not consistently applied.
5) No agreement on how to do diagnose DAP.
Is DAP real or mythical? 9
Profile limitations.
1) DAP profile overlaps autism behaviour profile
(O’Nions et al 2018).
2) Autism dx from age 3+, as when behaviours
consistently manifests (Green 2018).
3) “Passive Early History” & Avoidant behaviours
are generic, with anecdotal evidence open to
confirmation bias.
4) Assumptions on ontology, nosology & aetiology
of DAP should avoid anecdotal evidence.
Is DAP real or mythical? 10
Main DAP Discourse.
1) DAP originally a PDD.
2) Public often called PDD nosology group
“autistic spectrum”.
3) Demand Avoidance was obsessive (Newson et
al 2003).
4) DAP is not autism but part of autism spectrum
(Christie 2007; Christie et al 2012).
Is DAP real or mythical? 11
Anxiety and autism.
1) DAP’s main impairment is high anxiety driven
demand avoidance.
2) Current autism nosology, is validity based.
3) Anxiety is a comorbid, external to autism.
4) Anxiety prevalence rate 42 56% (Woods
5) Anxiety disorders prevalence around 20% (Lai
et al 2019.
6) OCD prevalence around 9% (Lai et al 2019).
7) DAP being an autism subtype is a false
equivalence fallacy.
Is DAP real or mythical? 12
PDA Development Group Definitions.
1) Demand avoidance had been present since
early infancy and presented across contexts
and time.” (Eaton, 2019).
2) Autistics persons transition between subtypes
(Wing 2002; Wing et al 2011).
3) Around 30% autistics develop into a different
subtype (Wodka et al 2013).
4) Definitions means autistics cannot transition
into DAP profile.
Is DAP real or mythical? 13
PDA Development Group Definitions.
1) Avoidance is pervasive and often seems
illogical or perverse (e.g. the child may be
unable to eat whilst hungry).’”
2) Avoidance is not limited to a specific
activity (or activities, e.g. school) or
activities in a specific context.” (Eaton,
3) Anxiety = Obsession.
4) Demand Avoidance = Compulsion.
Is DAP real or mythical? 14
SOR Developmental Model (Howard 2017).
Is DAP real or mythical? 15
Monotropism DAP Model.
1) Howard Model can be adapted for Sensory
Under Responsivity & Monotropism.
2) Crucially, this from birth.
3) Howard Model is applicable for trauma-based
developmental delays; can explain DAP.
4) Neurological differences can be from during
Is DAP real or mythical? 16
Not Autism.
1) Theory of Mind issues not specific to autism
(Chown 2017; Fletcher-Watson & Happé 2019).
2) RRBIs and Social Communication issues are not
specific to autism.
3) Quasi autism” (Runswick-Cole et al 2016).
4) Attachment-based autism (Colley & Cooper
5) There is nothing to prevent DAP changing
nosology group.
Is DAP real or mythical? 17
A content analysis.
1) DAP has no specificity (Attwood 2018; Christie
et al 2012; Christie & Fidler 2015; Garralda
2003; Kay 2019; Malik & Baird 2018; Wing
2) Signs of DAP seen in Asperger’s case studies
(Falk 2019; Philip & Contejean 2018; Sanchez
3) Traits applicable to many persons in
attachment/ trauma/ LAC literature & other
Is DAP real or mythical? 18
Non-Specific Nature.
1) Large overlap between many of these (Rutter
& Pickles 2016).
2) Such comorbidities are being seen in recent
samples (Brede et al 2017; Eaton 2018b; Egan
et al 2019; Kaushik et al 2015; Lyle &
Leatherland 2018; Trundle et al 2017).
3) Interaction with comorbidities affects autism
development (Brede et al 2017; Flackhill et al
2017; Green et al 2018a; Verhoeff 2012).
4) Can be difficult to differentiate between
comorbids & autism.
Monotropism & DAP. 19
A content analysis.
1) Nick Chown analysed BAP and autistic traits
tools for specificity (2019).
2) Suggests these 2 terms are result of word
games as they these constructs lack
3) DAP is argued to fall under BAP (Eaton 2018a).
Monotropism & DAP. 20
A content analysis.
1) Replicating Chown (2019) study with validated
2) RQ: To what extent do current
research/diagnostic tools identify features
specific to DAP?
Monotropism & DAP. 21
EDA-Q Limitations.
1) Extreme Demand Avoidance Questionnaire is a
screening tool; EDA-Q.
2) 26 item observer rated screening tool.
3) 4 point Likert Scale around likeness to child.
4) 2 threshold values; 50 for 11 years and under,
and 45 for 12 years and above.
Monotropism & DAP. 22
EDA-Q Limitations.
1) EDA-Q flaws: has a rater bias (Green et al
2018a) and divergent scores across
stakeholders (Brede et al 2017).
2) EDA-Q flaws: Detects demand avoidance
behaviours in other conditions & false
positives (Eaton 2018b; Green et al 2018a;
Kaushik 2015; O’Nions et al 2014a).
3) Unproven ability to discriminate against SEBD
(O’Nions et al 2014a).
Monotropism & DAP. 23
EDA-Q Limitations.
1) Ceiling effect, as anchor points are not very
sensitive in capturing variations at the more
extreme end (Stuart et al 2019).
2) Tool has not been standardised compared to
current diagnostic criteria, e.g no items for
assessing Sensory Differences.
3) pathologises behaviours children naturally
display when asserting their self-agency in
hard times (Moore 2020).
Monotropism & DAP. 24
Screening & diagnostic tools.
1) Extreme Demand Avoidance-Questionnaire for
Adults (EDA-QA), screening tool.
2) 26 item self rated screening tool.
3) 5 point Likert Scale.
4) Validated for general population.
Monotropism & DAP. 25
EDA-QA Limitations.
1) Allison Moore’s (2020) critique of EDA-Q
pathologising self-agency is applicable to EDA-
2) Autistic persons & DAPers are both prone to
internalising (Woods 2019b).
3) Open to confirmation from generic nature of
items and DAPers prone to internalising.
Is DAP real or mythical? 26
Diagnostic tool flaws.
1) Diagnostic Interview for Social and
Communication Disorders; DISCO.
2) Semi-structured interview schedule.
3) Clinician assesses each item based on
responses from other persons.
4) Only tested on 27 persons who met full
Newson profile, 1 was not autistic.
5) Takes 2 scores, worst case scenario & current
value for each item.
Is DAP real or mythical? 27
Diagnostic tool flaws.
1) Does not take into account fantasy & roleplay
traits (Philip & Contejean 2018).
2) Only measures 7 of 10 profile traits.
3) Untested discriminatory ability with SEMH.
4) Validated with arbitrary thresholds (O’Nions et
5) Vague & unspecific questions reliant on
caregiver reports (Lord et al 2018), open to
confirmation bias.
Is DAP real or mythical? 28
Diagnostic tools & conflicting diagnostic traits.
1) Some are trying to change descriptions of DAP
criteria to reflect it being an autism subtype.
2) E.g. “Appears sociable, but lacks
understanding” (Green et al 2018a, p3).
3) Not enough evidence to justify changes, this
study gives reasons to not use changed
diagnostic traits.
4) Proposed changes matter to how DAP is
conceptualised and treated.
Is DAP real or mythical? 29
Diagnostic tools & conflicting diagnostic traits.
1) Changed criteria do not reflect Newson’s or
Christie’s views on DAP. E.g.
2) Surface sociability, but apparent lack of
sense of social identity, pride, or shame.
(Newson et al 2003, p597).
3) “Lacking pride/ shame/ identity” ≠ “Lacks
4) Former associated to trauma, latter to
Is DAP real or mythical? 30
Diagnostic tools & conflicting diagnostic traits.
1) EDA-Q, EDA-QA, all DAP DISCO items
(validated & not) & Newson’s unvalidated
semi-structured interview are based on
Newson’s diagnostic criteria.
2) Any research or clinical practice that uses
changed criteria, while utilising above tools;
its validity is automatically undermined.
3) Researchers & clinicians need to use Newson’s
diagnostic traits.
Is DAP real or mythical? 31
General themes.
1) Assessed each item twice if it is specific to
autism or DAP. I then gave a reason to justify
each of the 126 answers [slightly more
extensive methodology of (Chown 2019)].
2) Then loosely looked at justifications to see if
there were general groupings emerging.
3) Admittedly it has just occurred to me I could
tally up the number of answers meeting each
theme! I will do this in the published write up
(aiming to discuss it in a book chapter).
Is DAP real or mythical? 32
General themes.
1) Either associated with trauma or highly
distressed persons.
2) Actions any person would display to assert
their self-agency.
3) Small minority of items can be found in
criminal activities, such as harassment of
Is DAP real or mythical? 33
First theme.
1) Either associated with trauma or highly
distressed persons. Examples:
2) Seems as if s/he is distracted ‘from within’
(O’Nions et al 2014, p763).
3) Knows what to do or say to upset specific
people.” (O’Nions et al 2014, p763).
4) “(Lacks) Awareness of own identity.(O’Nions
et al 2016, P415).
5) I am driven by the need to be in charge.
(Egan et al 2019, p485).
Is DAP real or mythical? 34
Second theme.
1) Actions any person would display to assert
their self-agency. Examples:
2) I complain about illness or physical
incapacity to avoid a request or demand.
(Egan et al 2019, p485).
3) Attempts to negotiate better terms with
adults.” (O’Nions et al 2014, p763).
4) Apparently manipulative behaviour.
(O’Nions et al 2016, p415).
Is DAP real or mythical? 35
Third theme.
1) Small minority of items can be found in
criminal activities. Examples:
2) Fantasising, lying, cheating, stealing.
(O’Nions et al 2016, p415)
3) Harassment of others.” (O’Nions et al 2016,
4) I tell other people how they should behave,
but do not feel these rules apply to me.
(Egan et al 2019, p485).
Is DAP real or mythical? 36
Clinical Populations.
1) Chown’s results suggest wider undiagnosed
autistic population (2019).
2) These results do not support this.
3) Substantial number of items are associated
with trauma based constructs.
4) Efforts to control numbers DAPers diagnosed
to maintain integrity of main discourse
(Christie 2018; Christie 2019; Summerhill &
Collett 2018).
5) Historically & presently, DAP is mainly
diagnosed in suspected autistic persons.
Is DAP real or mythical? 37
Clinical Populations.
1) Results do not support notion DAPers are an
undiagnosed autistic population.
2) Do indicate that DAPers are undiagnosed non-
autistic population.
3) EDA-Q detects demand avoidance outside of
autism (Eaton 2018b; Green et al 2018a;
Kaushik 2015; O’Nions et al 2014a).
4) This research indicates that such results are
probable identifications of DAP outside of
Is DAP real or mythical? 38
Future Directions.
1) Urgent need for good quality research into all
10 DAP criteria and tools are validated to
assess these.
2) Tentatively supports anecdotal reports DAP is
seen outside of autism (Dore 2016; Gillberg
2014; Kay 2019; McElroy 2016).
3) And emerging empirical evidence DAP is seen
in non-autistic persons (O’Nions 2013; O’Nions
et al 2016; Reilly et al 2014; Woods 2019b).
Is DAP real or mythical? 39
Future Directions.
1) Likewise, refutes notion DAP is an autism
2) This is important as it undermines validity of
any DAP research that assumes it is a form
(subtype/ profile/ disorder) of autism.
3) Need to use Newson’s diagnostic traits.
Is DAP real or mythical? 40
Clinical & Research Implications.
1) DAP is not a form of autism; clinically and for
research purposes should be treated as such.
2) Arguments for rights to a diagnosis are equally
applicable to non-autistic DAPers.
3) Results need replication studies on future DAP
tools, that are validated.
4) Threat to self-agency means DAP needs to be
treated with caution until research establishes
a consensus over what it is.
Is DAP real or mythical? 41
1) I am a researcher, not a clinician. Other
persons may draw divergent results.
2) There is no agreement over what DAP is.
3) 11 DISCO DAP items research is poor quality.
4) No tool measures all 10 DAP criteria.
5) Possible future research may reveal features
that are specific to DAP.
6) Generic language for DISCO; EDA-Q & EDA-QA
items predisposes dataset to support
Is DAP real or mythical? 42
1) Significant disagreement over what DAP is.
2) Judy Eaton’s DAP Database has significant
limitations based on axiology & the tools used.
3) Strategies are good practice & overlap many
4) Substantial overlap between trauma based
scholarship & DAP literature.
5) Need to use Newson’s diagnostic traits.
6) This is a simple study to conduct in a few
hours, please do replicate it for yourself.
Is DAP real or mythical? 43
1) I thank Dr Nick Chown for producing his
original content analysis of BAP and Autistic
Traits tools.
Is DAP real or mythical? 44
The End Game.
1) Contact Details:
2) Twitter handle:
3) My researchgate:
4) Any questions?
Is DAP real or mythical? 45
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Conference Paper
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Over the last decade or so, Pathological Demand-Avoidance (PDA) is often viewed as a “Profile of ASD” in the United Kingdom (UK). Despite over 20 years of substantial debate contesting the nature of PDA, and it lacking any robust evidence to suggest what PDA might be. This begs the question, why is PDA a “culture-bound concept” in the UK? Recognising all mental Disorders are socially constructed, this video examines different outlooks of PDA and how they evolved over time. Additionally, how different aspects of culture and biology intersect, to “PDA Profile of ASD” as a “culture-bound concept” to the UK. Consequently, creating a model of thirteen different themes of factors contributing to the biased hype surrounding PDA. Other Critical Autism Studies scholars can replicate. This video should be of interest to anyone critically engaging with PDA. Slides may slightly differ to those presented.
Conference Paper
Full-text available
Presently, in the United Kingdom, Demand-Avoidance Phenomena (DAP, sometimes called “Pathological Demand Avoidance”) is simultaneously gaining significant interest and controversy. Its leading proponents assert that DAP is one of the autism spectrum disorders, despite the lack of consensus and evidence to indicate what it is, and how to view DAP. Consequently, there is much debate over how to conceptualise DAP, with divergent outlooks for DAP pathologising features not typically included in an autism diagnosis, to DAP being a magpie disorder containing features from many accepted diagnostic entities. This talk we discuss its four main schools of thought, and they each evolved. Finally, focusing on how DAP can be conceptualised as a standalone diagnosis, and can be modelled as a generic stress management process. These are the slides delivered to a talk to Children and Technology Lab: University of Sussex on the 18th of November 2021. The talk is intended to provide an overview on how PDA might be conceptualised by those studying PDA. Potential discussion topics further resources. What the academic literature says about Newson et al (2003):� Why we should ignore Phil Christie's views DAP is an Autism Spectrum Disorder video:� Comprehensive overview to DAP & its broader debates seminar:� How “DAP Profile of ASD” is used to control autism stakeholders video:�
Full-text available
Pathological Demand Avoidance (PDA) is a proposed Disorder, which is sometimes viewed to be an autism spectrum disorder. Is characterised by persistence avoidance of ordinary demands by non-autistic society, with persons frequently displaying social avoidance behaviours which can be considered "manipulative" or "strategic". Presently, there is much controversy surrounding PDA, partly because there is no conclusive evidence to indicate which features comprise PDA, and how it should be conceptualised. Thus, there are competing divergent schools of thought on how to view PDA. This short paper describes the four main worldviews on PDA besides it being an autism spectrum disorder. Firstly, PDA is also conceptualised as "rebranded autism", pathologising characteristics not assessed in an autism diagnosis. Secondly, a common disorder. Finally, PDA could be a pseudo-syndrome resulting from the simultaneous interaction between autism and common co-occurring conditions. I call for treating with PDA caution until good quality scientific method-based research indicates which outlook should be adopted.
Conference Paper
Full-text available
These are slides of my 15 minute talk on why PDA can be viewed as a discrete Disorder at a lower diagnostic threshold. During the talk, I did not have time to fully describe or comment on all slides to as much detail as I like. I can answer any questions about particular slides.
Full-text available
This article explores key reasons for justifying the proto impairment of Demand Avoidance Phenomena (DAP), by investigating the integrity and validity of the construct. DAP is aggressively pushed by non-autistic stakeholders as an autism subtype, to date the circularity around DAP’s construction and operation has received little attention. We deconstruct evidence for DAP and contextualise the DAP profile in wider discourses, specifically of medical, ethics and working practices with autistic persons. Crucially, we demonstrate there is no cognitive or behavioural trait specific to DAP. Finally, we present the results of citation survey that indicate the DAP community has formed a community of practice and we discuss the implications this has on the language around the construct. The circular approach to the construct undermines efforts to research it, while providing a misleading picture of current evidence levels and wider debates. We propose that going forward the scientific method and embracing its’ conflicting nature, is the ethical manner to approach DAP.
Full-text available
Pathological (“extreme”) demand avoidance (PDA) involves obsessively avoiding routine demands and extreme emotional variability. It is clinically linked to autism spectrum disorder (ASD). The observer-rated EDA Questionnaire (EDA-Q) for children was adapted as an adult self-report (EDA-QA), and tested in relation to personality and the short-form Autism Screening Questionnaire (ASQ). Study 1 (n = 347) found the EDA-QA reliable, univariate, and correlated with negative affect, antagonism, disinhibition, psychoticism, and ASQ scores. Study 2 (n = 191) found low agreeableness, greater Emotional Instability, and higher scores on the full ASQ predicted EDA-QA. PDA can screened for using this tool, occurs in the general population, and is associated with extremes of personality. Future studies will examine if PDA occurs in other clinical populations. Electronic supplementary material The online version of this article (10.1007/s10803-018-3722-7) contains supplementary material, which is available to authorized users.
Full-text available
Background: A subset of individuals with autism spectrum disorder (ASD) resemble descriptions of extreme/'pathological' demand avoidance, displaying obsessive avoidance of everyday demands and requests, strategic or 'socially manipulative' behaviour and sudden changes in mood. Investigating challenging presentations using dimensional description may prove preferable to identifying subgroups. However, there remains an imperative to explore which behavioural traits appear most problematic to inform quantitative investigation. This study provides an in-depth exploration of parent perspectives on maladaptive behaviour in children reported to have an autism spectrum diagnosis and features of extreme/'pathological' demand avoidance. Method: Parents completed a tailored semistructured interview about their child's behaviour, focusing on difficulties relevant to descriptions of extreme/'pathological' demand avoidance. The 26 interviews rated as scoring above threshold for 'substantial' features of extreme/'pathological' demand avoidance on relevant indicators were analysed qualitatively using a general inductive approach. Results: New themes that emerged from these data included attempts by the child to control situations and others' activities. Avoidance behaviours in this sample could be described as 'strategic' rather than 'manipulative'. A range of factors, including a negative emotional response to demands, but also phobias, novelty, and uncertainty, were perceived to play a role in triggering extreme behaviour. Conclusions: These descriptions highlight the importance of systematically measuring noncompliance, attempts to control situations and others' activities, and extreme mood variability in individuals with ASD. These dimensions represent important targets for intervention, given their considerable impact on daily life.
The term ‘pathological demand avoidance’ was first coined in 1983. In recent years, diagnostic tools have emerged to enable practitioners to identify, name and treat pathological demand avoidance and, at least in the United Kingdom, there is an increasing number of children who attract this label. In addition to what are defined as the core ‘deficits’ of autism, including assumed difficulties in social communication, difficulties in social interaction and restrictive interests, children with pathological demand avoidance are thought to have an extreme anxiety-driven need to control their environment and control the demands and expectations of others. This article will argue that we must exercise extreme caution in accepting the validity of pathological demand avoidance and will suggest that it can be seen as an attempt to psychiatarise autistic children’s resistance, which, in so doing, restricts their agency. First, it will draw on the arguments put forward by some autistic scholars who have claimed that pathological demand avoidance is better understood as rational demand avoidance – an understandable and rational response to the circumstances that one finds oneself in. Second, it will consider the intersection between autism and childhood. When one of the defining characteristics of pathological demand avoidance is an inability to recognise and, presumably, respect social hierarchy, children’s competencies as social actors and active meaning makers of their world can easily become pathologised as defiance. Finally, the article will address the intersections of autism, childhood and gender. Girls are much less likely to be diagnosed as having an autism spectrum condition than boys are, with a ratio traditionally estimated at approximately 1:4. However, pathological demand avoidance diagnoses are fairly evenly spread between boys and girls. It will be argued that it is girls’ resistance to the ordinary and everyday demands of her as a girl and her subsequent rejection or transgression of those expectations that is being pathologised.
Background Pathological demand avoidance (PDA) is a proposed subtype of autism spectrum disorder (ASD), characterised by extreme avoidance of demands. Demand avoidant behaviour has been proposed to be driven by an anxious need to be in control, although has never been explicitly studied. Emerging evidence suggests intolerance of uncertainty (IU) and anxiety may explain the behaviours seen in ASD. We propose these concepts may be useful starting points for furthering understanding of PDA. Methods In Study 1, quantitative methods examined the relationship between PDA, IU and anxiety using data collected in an online survey (N = 214). The sample included cases with clinically diagnosed PDA (n = 69) and those with no clinical diagnosis but parent‐identified features of PDA (n = 151). ‘Children with a diagnosis of PDA scored significantly higher on the IUS‐P (t(212) = 2.45, p < .05) compared to those without a diagnosis of PDA. PDA diagnosis did not impact on scores on any other measure.’ In Study 2, a selection of Study 1 participants (n = 11) were followed up with a telephone interview to gain descriptive data relating to PDA and its association with IU and anxiety. Results Regression analyses indicate that demand avoidant behaviour can be conceptualised in part as a possible attempt to increase certainty and predictability to alleviate increasing anxiety. Children and young people with PDA employed varying strategies to manage IU depending on the level of demand presented and degree of anxiety generated. These strategies can be represented by different features of the behaviour profile seen in PDA (control behaviour, withdrawal to fantasy, and meltdown). These behavioural features of PDA showed differential relationships with IU and anxiety, although all were predicted by IU, only meltdown demonstrated a mediation effect by anxiety. Conclusions This study represents one of the first attempts to conceptualise and understand the behavioural features of the PDA profile in children and young people. It builds upon emerging evidence from the ASD literature that IU is a relevant construct for conceptualising demand avoidant behaviour in children who show PDA behaviour. This has potential clinical implications for the assessment and management of PDA in children and young people.
Pathological demand avoidance (PDA), a term first used by Elizabeth Newson in the 1980s, refers to a collection of behaviours that children will demonstrate to avoid instructions (and tasks) that they perceive as demands. These children are postulated to be averse to anything that is perceived as a demand placed on them. PDA features are commonly encountered in children with autism but PDA is not a subtype of autism nor a separately diagnosed mental, behavioural or developmental disorder in any of the major classification systems (ICD‐10 or DSM‐5). Such behaviours are not confined to children with autism and debate continues regarding its existence as a distinct phenomenon and if such a phenotype exists whether it is merely a part of autism or a separate condition. We comment on O'Nions and colleagues’ study that explores common themes/behavioural traits in children with autism spectrum disorder (ASD) who also fit the phenotypic description of PDA. We explore how the current classification systems capture features of PDA in autism with diagnoses of common comorbidities in ASD (such as disruptive behaviour/conduct disorders, OCD and anxiety), but to many clinicians and parents this seems an inadequate description. What remains to be explored are the trans‐diagnostic temperamental and cognitive traits of children with PDA features, such as cognitive rigidity and intolerance of uncertainty. It is important to understand why some children are demand avoidant and identification of these factors (individual and systemic) helps in management much more than classifying them with an additional label. O'Nions et al. have helpfully provided further insight into several underpinning traits/dimensions of children with PDA features; understanding these will help develop effective strategies for parenting demand‐avoidant children. Read the Response to this article at doi: 10.1111/camh.12287
This is a short definition entry on Pathological Demand Avoidance (PDA). It is covers all extant names of PDA, its diagnostic criteria and how its behaviour profile differs from established subtypes. Additionally, the chapter covers PDA's contested nature by providing all its present ontologies that are in print. Finally. the entry discusses the PDA strategies. Core critique of PDA are noted, providing a picture of the current debates on PDA. Many thanks to Liz O'Nions for her constructive feedback on the development of the entry.
Pathological (or extreme) demand avoidance is a term sometimes applied to complex behaviours in children within—or beyond—autism spectrum disorder. The use of pathological demand avoidance as a diagnosis has, at times, led to altered referral practice and misunderstandings between professionals and the families of patients. In our Viewpoint, we reviewed the current literature and conclude that the evidence does not support the validity of pathological demand avoidance as an independent syndrome. Nevertheless, the use of the term highlights an important known range of co-occurring difficulties for many children with autism spectrum disorder that can substantially affect families. We explore how these difficulties can best be understood through understanding of social, sensory, and cognitive sensitivities in autism spectrum disorder, identification of frequently occurring comorbid conditions, and assessment of how these problems interact within the child's social environment. Such understanding should then inform individualised management strategies for children and families, and in social settings, such as education. It is crucial that a shared understanding is achieved between professionals and families in this area.