Abstract
'Pathological Demand Avoidance' is a term increasingly used by practitioners in the United Kingdom. It was coined to describe a profile of obsessive resistance to everyday demands and requests, with a tendency to resort to 'socially manipulative' behaviour, including outrageous or embarrassing acts. Pathological demand avoidance is thought to share aspects of social impairment with autism spectrum disorders, but autism spectrum disorder-appropriate strategies, such as routine and repetition, are described as unhelpful. Outrageous acts and lack of concern for their effects draw parallels with conduct problems and callous-unemotional traits. However, reward-based techniques, effective with conduct problems and callous-unemotional traits, seem not to work in pathological demand avoidance. Despite increasing interest and controversy over the pathological demand avoidance label, there is only one published study to date. We present the first systematic comparison of the behavioural profile of children receiving the term pathological demand avoidance (N = 25) to children with autism spectrum disorders (N = 39) or conduct problems and callous-unemotional traits (N = 28), using parent-report indices of psychopathology. The pathological demand avoidance group displayed comparable levels of autistic traits and peer problems to the autism spectrum disorders group and anti-social traits approaching those seen in the conduct problems and callous-unemotional traits group. Emotional symptoms in pathological demand avoidance exceeded both comparison groups. Findings highlight the extreme behavioural impairment associated with pathological demand avoidance and the need to explore whether behavioural overlap reflects a similar neurocognitive basis to existing groups.
Highlights
A major challenge in clinical practice is that cases fail to respect diagnostic or conceptual boundaries, often presenting a confusing or atypical picture
The z-scores indicated that the means of Pathological Demand Avoidance’ (PDA) and autism spectrum disorders (ASD) groups were in the most affected 1% of the population sample for Childhood Autism Spectrum Test (CAST) total score
Analyses of CAST sub-scales indicated a main effect of group across subscales (F(2, 89) = 10.00, p < .001), but the group × subscale interaction failed to reach significance (F(4, 178) = 2.18, p = .074; Pillai’s trace)
Summary
A major challenge in clinical practice is that cases fail to respect diagnostic or conceptual boundaries, often presenting a confusing or atypical picture. While it is acknowledged that the social presentation of individuals with autism spectrum disorders (ASD) can vary substantially (Wing, 1991), most accounts indicate diminished social motivation, social naivety or social peculiarity. These typical social presentations, indexed via difficulties developing a rapport, maintaining to and fro conversation and responding in a socially appropriate manner, form a key component of our concept of autism. ‘Pathological Demand Avoidance’ (PDA) is a term coined by Newson et al, (2003) to describe children who, while ‘reminiscent of autism’, show surprising and challenging features within autism services. There is disagreement and debate as to whether PDA is truly a syndrome, or whether it labels specific behaviours seen in children with a
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