Demand Avoidance Research Articles

Commentary: Conceptualising demand avoidance in an ASD context - a response to Osman Malik & Gillian Baird (2018).

Malik and Baird (this issue) have raised a number of important points drawing on our study of parent-reported dimensions of difficulty in children with features of extreme/'pathological' demand avoidance. In particular, they highlight the pressing need to understand why some children exhibit problematic demand avoidance, and identify factors that promote and maintain these behaviours. As Green etal. () note, children with ASD often show a strong reactivity to the environment. As such, stimuli, activities or interactions that present no problems for typically developing children may unexpectedly provoke extremes of affect. Both Green and colleagues (2018) and Malik & Baird (this issue) highlight a number of possible contributory factors, including sensory sensitivities, difficulty in predicting outcomes, need for sameness, poor tolerance of uncertainty, and fluctuations in autonomic arousal.

The Measurement of Adult Pathological Demand Avoidance Traits

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.

Neural systems of cognitive demand avoidance

Cognitive effort is typically aversive, evident in people's tendency to avoid cognitively demanding tasks. The ‘cost of control’ hypothesis suggests that engagement of cognitive control systems of the brain makes a task costly and the currency of that cost is a reduction in anticipated rewards. However, prior studies have relied on binary hard versus easy task subtractions to manipulate cognitive effort and so have not tested this hypothesis in “dose-response” fashion. In a sample of 50 participants, we parametrically manipulated the level of effort during fMRI scanning by systematically increasing cognitive control demands during a demand-selection paradigm over six levels. As expected, frontoparietal control network (FPN) activity increased, and reward network activity decreased, as control demands increased across tasks. However, avoidance behavior was not attributable to the change in FPN activity, lending only partial support to the cost of control hypothesis. By contrast, we unexpectedly observed that the de-activation of a task-negative brain network corresponding to the Default Mode Network (DMN) across levels of the cognitive control manipulation predicted the change in avoidance. In summary, we find partial support for the cost of control hypothesis, while highlighting the role of task-negative brain networks in modulating effort avoidance behavior.

Cue awareness in avoiding effortful control

Based on a recent metacognitive account, cognitive effort is the result of an inferential evaluation made over explicitly available cues. Following from this account, we present here a pre-registered experiment that tested the specific hypothesis that explicit awareness of cues that are aligned with cognitive demand is a prerequisite in avoiding effortful lines of action. We attempted to modulate levels of effort avoidance behavior by introducing an incentive (between-subjects) to monitor two lines of action that, unbeknownst to individuals, varied in the probability of a task switch. Importantly, previous research has demonstrated that the difference in these probabilities is relatively opaque to individuals. We did not find strong evidence for our incentive manipulation having an effect on demand avoidance as indexed by individuals’ choices in a block of the task where avoiding effort was instructed. However, we do find that being aware of the task-switching cue appears to increase the likelihood of demand avoidance. We consider these results within the context of the metacognition of cognitive effort.

Adaptive control and the avoidance of cognitive control demands across development

Young adults adaptively coordinate their behavior to avoid demands placed on cognitive control. We investigated how this adaptive coordination develops by having 6–7- and 11–12-year-olds and young adults complete a demand selection task, in which participants could select between two tasks that varied in cognitive control demands via differences in rule switch frequency. Adults and older children exhibited significant preference for selecting the less demanding task, as well as a metacognitive signal guiding adaptive demand avoidance behavior across a variety of behavioral and self-report assessments. In contrast, despite evidence of differential demands on cognitive control, younger children did not coordinate their task selections to avoid higher demand. Together, these findings suggest that sensitivity and adaptive responses to control demands emerge with development and are consistent with gradual development of lateral prefrontal cortex, dorsal anterior cingulate cortex, and their functional connectivity, which support effort avoidance in adults.

Pathological Demand Avoidance: symptoms but not a syndrome

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.

Le syndrome d’évitement pathologique des demandes : psychopathie autistique ? Syndrome d’Asperger ? Autisme atypique ? Ou trouble envahissant du développement (TED) spécifique ?

The aim of this paper is to inform French clinicians about “pathological demand avoidance” syndrome, also referred to as PDA, described by Elizabeth Newson (1929–2014), professor of developmental psychology at the University of Nottingham in the 1980s. E. Newson discerned a particular behavioral pattern in a subgroup of children who were referred to her for suspicion of autism or Asperger's syndrome without confirmed diagnostic assessment. These children have an inability to tolerate demands imposed upon them and try to resist with strategies of avoidance; being essentially socially manipulative is not compatible with the shared representation of autism. They give an impression of sociability, but they often lack a sense of social identity (e.g. believing themselves to be on a par with or superior to adults), pride or shame. They have mood swings led by need to control their relationship. They appear comfortable in role playing and pretending – often adopting borrowed roles when interacting with others (e.g. relating to peers in the manner of a teacher). In recent years, PDA has attracted increasing clinical attention mainly in the United Kingdom and Northern Europe, but little is known in France. Its validity as well as its place in the nosography are still being debated. E. Newson considered PDA to be a specific pervasive developmental disorder while other clinicians classified it in autism spectrum disorders (ASD). It remains true that PDA is a real clinical problem that imposes a therapeutic challenge: the need for these subjects to control the relationship makes it very difficult to treat. In this article, we illustrate the cardinal signs of this syndrome with a clinical case to facilitate its recognition. We discuss two differential diagnoses: oppositional defiant disorder and ASD. We found that the autistic psychopathy described by Hans Asperger resembles PDA. The interest of E. Newson's work is to highlight the affective and emotional presentation of the symptoms not described in DSM-5 which only emphasizes the deficits of social cognition (deficits in socio-emotional reciprocity, non-verbal communication, restricted interests etc.). Educational approaches effective for PDA differ from “typical” ASD and include novelty, humor and flexibility.

Dimensions of difficulty in children reported to have an autism spectrum diagnosis and features of extreme/'pathological' demand avoidance.

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. 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. 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. 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.

Differentiating between pathological demand avoidance and antisocial personality disorder: a case study

PurposeThe purpose of this paper is to explore the different clinical features of pathological demand avoidance (PDA) and antisocial personality disorder (ASPD) presented in the form of a single case study. The study highlights the potential of misdiagnosis and conceptual confusions to practitioners in forensic settings between the two conditions when working with offenders with personality disorders.Design/methodology/approachA case formulation using the “five Ps” method based on the personal history of an incarcerated male is presented and the clinical similarities and differences between PDA and ASPD are delineated. These differences and similarities are evaluated and applied to offender management including intervention options.FindingsThere are considerable similarities between ASPD and PDA making the two conditions difficult to separate. Both diagnostic criteria identify childhood behavioural problems, aggression, destructiveness, conduct disorder (CD), manipulation and non-compliance as indications of the disorder. For example, the criteria for later adult ASPD are the presence of childhood antisocial behaviour and CD. However, these behaviours may also be suggestive of the attention deficit hyperactivity disorder and non-compliance that are part of PDA. Violent behaviours and aggression can also be perceived in a similar way. Misdiagnosis of PDA as ASPD reduces the efficiency of treatment programmes.Originality/valueThe implications of these findings could prove useful in the successful risk management of offenders with PDA. Given the similar behavioural characteristics between PDA and ASPD, the prevalence of PDA among offenders may be higher than observed. The aim of this study is to raise awareness of potential conceptual complications and clinical confusions between the two conditions with a view to aid offender management through case formulation. A large scale study into offenders with PDA would draw attention to the prevalence of the condition as well as its association with offending behaviour.

Somatic increase of CCT8 mimics proteostasis of human pluripotent stem cells and extends C. elegans lifespan.

Human embryonic stem cells can replicate indefinitely while maintaining their undifferentiated state and, therefore, are immortal in culture. This capacity may demand avoidance of any imbalance in protein homeostasis (proteostasis) that would otherwise compromise stem cell identity. Here we show that human pluripotent stem cells exhibit enhanced assembly of the TRiC/CCT complex, a chaperonin that facilitates the folding of 10% of the proteome. We find that ectopic expression of a single subunit (CCT8) is sufficient to increase TRiC/CCT assembly. Moreover, increased TRiC/CCT complex is required to avoid aggregation of mutant Huntingtin protein. We further show that increased expression of CCT8 in somatic tissues extends Caenorhabditis elegans lifespan in a TRiC/CCT-dependent manner. Ectopic expression of CCT8 also ameliorates the age-associated demise of proteostasis and corrects proteostatic deficiencies in worm models of Huntington's disease. Our results suggest proteostasis is a common principle that links organismal longevity with hESC immortality.

Parents’ experiences of professionals’ involvement for children with extreme demand avoidance

Objectives: Pathological demand avoidance (PDA) is characterized by an extreme difficulty in tolerating everyday demands, with a range of ‘socially manipulative’ strategies used to avoid demands. Children also display poor social identity, impulsivity, and obsessive behavior. While research and knowledge about PDA is slowly growing, families continue to encounter considerable difficulties in ensuring their children’s needs are understood and met by health and education services. This study explored what parents of children with extreme demand avoidance valued about professionals’ input.Methods: Parents of 42 children who scored above the cut-off on a standardized measure with validated sensitivity and specificity for PDA responded to questionnaire items asking them to identify professionals’ involvement and helpfulness. They were also asked what had characterized the most helpful professional involvement. Thematic analysis was used to identify the key themes in parents’ responses.Results: Families tended to have high levels of professional involvement. Most professionals were experienced as helpful by the majority of parents. Three main themes were identified as characterizing helpful involvement: enabling access to services and resources, concrete outcomes such assessments and management strategies, and professional-level factors such as skills and qualities.Conclusions: Parents felt positive about practitioners who had listened to their experiences, made efforts to understand the child, and provided or arranged for help. Parents found involvement most helpful when it resulted in comprehensive assessment, appropriate intervention, practical advice and management strategies, and a focus on the well-being of all family members. The overall ratings of helpfulness are encouraging, and the specific feedback about what is most helpful could be of value in shaping services.

The Power of Demand

Electrical demand management is a strategy used by utility companies to manage peak consumption. For commercial customers, utility companies often include electric demand charges for the maximum power used during a specified time period, measured in $/kW. This is in addition to the charge for power consumed measured in $/kWh. Rate structures generally vary by region and utility company, but the premise is the same. Strategies designed to avoid or minimize the impact of electric demand to reduce operating cost are not a new idea; however, these designs are used primarily in facilities that are large power users where the operation of energy consuming systems can be scheduled to take advantage of the rate structure.The energy performance of a building is dependent on choices made by the occupants about the proper use and maintenance of building systems. Thus, controlling and adjusting occupant behavior is important to ensuring the full potential of high performance facilities. Traditionally, the design team's role on a project ends when the building is built and all of the post-construction documentation is provided to the owner. Systems in modern-day buildings are complex, especially for users who lack training in architecture or engineering. These misunderstood systems are often incorrectly altered which ultimately impacts building energy consumption. Design, commissioning, and energy professionals can positively impact building performance by training the building occupants on how their systems work.The techniques for demand avoidance described in this article are so subtle that occupants rarely detect the changes. In this article, actual data and case studies are presented from educational facilities showing the cost of implementation and the return on investment (ROI). The ROI for these system improvements is commonly less than two years.

Metacognitive evaluation in the avoidance of demand.

In the current set of experiments our goal was to test the hypothesis that individuals avoid courses of action based on a kind of metacognitive evaluation of demand in a Demand Selection Task (DST). Individuals in Experiment 1 completed a DST utilizing visual stimuli known to yield a dissociation between performance and perceived demand. Patterns of demand avoidance followed that of perceived demand. Experiment 2 provided a replication of the aforementioned results, in addition to demonstrating a second dissociation between a peripheral physiological measure of demand (i.e., blink rates) and demand avoidance. Experiment 3 directly tested the assumption that individuals make use of a general metacognitive evaluation of task demand during selections. A DST was utilized in a forced-choice paradigm that required individuals to either select the most effortful, time demanding, or least accurate of 2 choices. Patterns of selections were similar across all rating dimensions, lending credit to this notion. Findings are discussed within a metacognitive framework of demand avoidance and contrasted to current theories. (PsycINFO Database Record

Identifying features of 'pathological demand avoidance' using the Diagnostic Interview for Social and Communication Disorders (DISCO).

The term ‘pathological demand avoidance’ (PDA) was coined by Elizabeth Newson to describe children within the autism spectrum who exhibit obsessive resistance to everyday demands and requests (Newson et al., Arch Dis Child 88:595–600, 2003). Clinical accounts describe avoidance strategies including apparently strategic use of distraction or socially shocking behaviour, and obsessive need for control, reflected in domineering behaviour to peers and adults. Educational and management approaches effective for PDA reportedly differ from those for ‘typical’ autism spectrum disorders (ASD), and include novelty, humour and flexibility. Identification of PDA in individuals with ASD may have important implications for management (Eaton and Banting, J Learn Disabil Offending Behav 3:150–157, 2012). Despite increasing interest, no clinician-rated instrument for PDA has been developed. Here, items relevant to PDA were identified from the Diagnostic Interview for Social and Communication Disorder (DISCO) (Wing et al., J Child Psychol Psychiatry 43:307–325, 2002). The most PDA-specific subset of relevant DISCO items was selected, based on low endorsement in general across a sample of 153 individuals assessed for possible ASD using the DISCO. Having selected 11 DISCO PDA items for the measure, a subset of individuals with a high number of these features was identified (N = 27). Consistent with Newson’s descriptions, this high scoring group was characterised by lack of co-operation, use of apparently manipulative behaviour, socially shocking behaviour, difficulties with other people, anxiety and sudden behavioural changes from loving to aggression. All but one case met criteria for an ASD. This study brings the field a step closer to a clinician-rated measure of PDA features and highlights the need for further elucidation of the PDA phenotype.Electronic supplementary materialThe online version of this article (doi:10.1007/s00787-015-0740-2) contains supplementary material, which is available to authorized users.

Mapping the educational experiences of children with pathological demand avoidance

‘Pathological demand avoidance’ (PDA) describes a pattern of difficulties increasingly recognised as forming part of the autistic spectrum. Although clinical reports suggest that children with PDA are likely to experience considerable difficulties in education, their educational experiences have not yet been explored in any systematic way. In the current study, 42 parents of children with PDA completed a questionnaire about their child's educational experiences. Parents' responses indicated that this group of children displays high levels of problem behaviours in school, and receives corresponding high levels of special educational need support and professional involvement. Despite this support, the group had experienced high rates of exclusion and placement breakdown, with only 48% now in mainstream education. Parents reported relatively high satisfaction in their children's educational placements, with success defined by parents in terms of child outcomes, school characteristics and PDA‐specific factors. Findings are discussed with reference to what is known about the educational experiences of children with more typical autism spectrum conditions and in terms of the implications for the inclusion of this group of children with complex needs.

Extreme ("pathological") demand avoidance in autism: a general population study in the Faroe Islands.

Research into Pathological Demand Avoidance (PDA), which has been suggested to be a subgroup within the Autism Spectrum Disorder (ASD), is almost nonexistent in spite of the frequent reference to the condition in clinical practice. The total population of 15 to 24-year-olds in the Faroe Islands was screened for ASD, and 67 individuals were identified who met diagnostic criteria for ASD (corresponding to a general population prevalence of ASD of almost 1 %). Of these 67, 50 had parents who were interviewed using the Diagnostic Interview for Social and Communication Disorders (DISCO-11) which contains 15 "PDA-specific" items. Nine individuals met criteria for "possible clinical diagnosis of PDA", meaning that almost one in five of all with ASD also had indications of having had PDA in childhood, and that 0.18 % of the total population had had the combination of ASD and PDA. However, at the time of assessment, only one of the 9 individuals with possible PDA still met "full criteria". PDA possibly constitutes a considerable minority of all cases with ASD diagnosed in childhood, but criteria for the condition are unlikely to be still met in later adolescence and early adult life.

Pathological Demand Avoidance in a population-based cohort of children with epilepsy: four case studies.

Childhood epilepsy is associated with a range of neurobehavioural comorbidities including Attention-Deficit/Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), motor impairments and emotional problems. These difficulties frequently have a greater impact on quality of life than seizures. Pathological Demand Avoidance (PDA) is a term increasingly in use in the UK and Europe to describe behaviours associated with an extreme resistance to demands and requests and the need to be in control in social interactions. In a population-based group of 85 children with epilepsy, four (5%) were identified as displaying significant symptoms of PDA, were assessed using the Extreme Demand Avoidance Questionnaire (EDA-Q) and are described in detail. As well as significant symptoms of PDA, the four children met criteria for a range of neurobehavioural disorders; all four had cognitive impairment (IQ<85) and met DSM-IV-TR criteria for ADHD. Three, in addition, met criteria for ASD and Developmental Coordination Disorder (DCD) and two for Oppositional Defiant Disorder (ODD). All four experienced their first seizure before 5 years of age. School and parent reports indicated very significant functional impairment and management concerns, particularly with respect to complying with everyday demands. Symptoms of PDA should be considered when evaluating neurobehavioural comorbidity in childhood epilepsy.

Cognitive effort avoidance and detection in people with schizophrenia.

Many people with schizophrenia exhibit avolition, a difficulty initiating and maintaining goal-directed behavior, considered to be a key negative symptom of the disorder. Recent evidence indicates that patients with higher levels of negative symptoms differ from healthy controls in showing an exaggerated cost of the physical effort needed to obtain a potential reward. We examined whether patients show an exaggerated avoidance of cognitive effort, using the demand selection task developed by Kool, McGuire, Rosen, and Botvinick (Journal of Experimental Psychology. General, 139, 665-682, 2010). A total of 83 people with schizophrenia or schizoaffective disorder and 71 healthy volunteers participated in three experiments where instructions varied. In the standard task (Experiment 1), neither controls nor patients showed expected cognitive demand avoidance. With enhanced instructions (Experiment 2), controls demonstrated greater demand avoidance than patients. In Experiment 3, patients showed nonsignificant reductions in demand avoidance, relative to controls. In a control experiment, patients showed significantly reduced ability to detect the effort demands associated with different response alternatives. In both groups, the ability to detect effort demands was associated with increased effort avoidance. In both groups, increased cognitive effort avoidance was associated with higher IQ and general neuropsychological ability. No significant correlations between demand avoidance and negative symptom severity were observed. Thus, it appears that individual differences in general intellectual ability and effort detection are related to cognitive effort avoidance and likely account for the subtle reduction in effort avoidance observed in schizophrenia.

Commentary: PDA – public display of affection or pathological demand avoidance? – reflections on O'Nions et al. (2014)

A group of children presents with a rather peculiar type of oppositional behaviours, sometimes now subsumed under the label of 'pathological demand avoidance' syndrome, also increasingly referred to as PDA. Boys and girls with 'this kind of PDA' will do anything to avoid meeting demands of adults and children alike. The behaviours 'used' in maintaining avoidance range from openly oppositional or manipulative to 'extreme shyness', passivity and muteness. These behaviours in terms of expression of affection are rather the opposite of those associated with the commonly used meaning of PDA. However, the avoidant behaviour is quite often 'publicly displayed' and with no feeling for the inappropriateness of the, sometimes even, exhibitionist style of extreme demand avoidance (EDA). The 'disorder' was first heard of in 1980, when Elisabeth Newson presented the first 12 cases of what she believed to be a 'new' and separate syndrome and that she referred to as PDA. Even though PDA has attracted quite a bit of clinical attention in the United Kingdom and other parts of Europe (including Scandinavia), virtually no research has been published in the field so far (Newson, Le Maréchal, & David, ). Experienced clinicians throughout child psychiatry, child neurology and paediatrics testify to its existence and the very major problems encountered when it comes to intervention and treatment. It is therefore a major step forward that O'Nions and co-workers (this issue) have developed a new 'trait measure' for PDA ('the EDA-Q'), a measure that appears to hold considerable promise for research, and eventually for clinical practice.

Pathological demand avoidance: Exploring the behavioural profile

'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.