Pathological Demand Avoidance Research Articles

Extreme or pathological demand avoidance: prioritising research to understand the prevalence and cause.

Extreme or pathological demand avoidance: prioritising research to understand the prevalence and cause.

The teacher's introduction to pathological demand avoidance: Essential strategies for the classroom By ClareTruman, London: Jessica Kingsley, 2021. £14.99 (Paperback)The educator's experience of pathological demand avoidance: An illustrated guide to pathological demand avoidance and learning By LauraKerbey, London: Jessica Kingsley, 2021. £13.99 (Paperback)

The teacher's introduction to pathological demand avoidance: Essential strategies for the classroom By ClareTruman, London: Jessica Kingsley, 2021. £14.99 (Paperback)The educator's experience of pathological demand avoidance: An illustrated guide to pathological demand avoidance and learning By LauraKerbey, London: Jessica Kingsley, 2021. £13.99 (Paperback)

Examining the relationship between anxiety and pathological demand avoidance in adults: a mixed methods approach

IntroductionPathological demand avoidance (PDA) is characterised by extreme avoidance of everyday demands. A recent study identified anxiety and intolerance of uncertainty (IU) as explanatory frameworks for understanding PDA in children, while anecdotal evidence suggests that anticipatory responses to uncertainty are also influential in the development and maintenance of PDA. Previous studies have relied upon parent-report of child representations of PDA; the lack of adult representation in the literature means that little can currently be said for how demand avoidance behaviours manifest in adulthood. The present study aimed to further an understanding of underlying mechanisms involved in the development and maintenance of PDA by recruiting a non-clinical adult cohort.MethodsExperiment 1 utilised a correlational survey design in order to ascertain the extent to which MASQ-D30, IUS-12, and SBI scores could be used to predict EDA-QA scores (N = 163). In experiment 2, a subsample of participants from experiment 1 (n = 13) gave their experiential perspective on anxiety, uncertainty, and anticipation.ResultsRegression analysis found only MASQ-D30 and IUS-12 scores to significantly predict that of the EDA-QA. Additionally, interpretive phenomenological analysis of participant transcripts revealed four main themes (approach-avoidance behaviour, factors influencing anticipatory bias, vulnerability factors associated with demand avoidance, and development).DiscussionTaken together, results from experiments 1 and 2 support the notion that anxiety and IU continue to play a role in the maintenance of PDA behaviours in adulthood, while participant descriptions implicate the role of anticipatory responses to uncertainty in the maintenance of demand avoidant behaviours in adults.

Rupture, repair, the loss and re-construction of identity: Seeking support in situations of adolescent-to-parent violence and abuse.

Family violence is associated with life-long implications including increased vulnerability to poor mental and physical health, and increased risk of repeat victimization. When children or adolescents are the ones instigating the harm, mothers experience the compounding issues of violence, mother-blame, and stigma. In comparison to other forms of family violence, how mothers understand and interpret their experiences of adolescent-to-parent violence and abuse (APVA) is underexplored, particularly in relation to what it means for them at the emotional and individual level, and how this impacts their sense of self, and their mothering and professional identities. This brief research report uses an interpretive phenomenological approach utilising hermeneutics to explore how six mothers made-meaning of their lives and identity when their parenting journey was disrupted by APVA. Help-seeking behaviours were often met with denial, avoidance, and parent-blame from professionals, unless they were familiar with the mother through her professional identity first. Neurodivergences of the adolescents were reported, including mental illness, autism, pathological demand avoidance, and foetal alcohol spectrum disorder. and as no mother reported successful engagement with social care, youth justice, or mental health services when help-seeking, they needed to reimagine their parenting role, or hit crisis, before accessing appropriate support. Mothers could have been supported earlier if critical incidents were identified by services, and support and/or interventions provided earlier, when mothers first engaged in help-seeking behaviours.

[Pathological Demand Avoidance: Current State of Research and Critical Discussion].

Pathological Demand Avoidance: Current State of Research and Critical Discussion Abstract: Pathological demand avoidance (PDA) describes children who obsessively avoid any demand to a clinically relevant extent and is presently the subject of controversial discussion. Their behavior may be interpreted as an attempt to reduce anxiety by establishing security and predictability through rigid control of the environment as well as the demands and expectations of others. The symptoms are described in the context of autism spectrum disorder. This article reviews the current state of research and discusses the questionable validity of pathological demand avoidance as an independent diagnostic entity. It also addresses the impact of the behavior profile on development and treatment. This paper concludes that PDA is not a diagnostic entity nor a subtype of autism; rather, it is a behavior profile that can be associated with adverse illness progression and unfavorable outcomes. PDA is one feature in a complex model. We must consider not only the patient's characteristics but also those of the caregiver and their psychopathology. The reactions of the interaction partners as well as the treatment decisions play a key role play for the affected individuals. Substantial research is needed concerning the occurrence of the behavior profile PDA in diverse disorders, treatment options, and treatment responses.

Mapping experiences of pathological demand avoidance in Ireland

Pathological demand avoidance (PDA) is contended to be a distinct presentation within autism characterised by extreme levels of anxiety in response to the demands of everyday life, manifested in excessive levels of demand avoidance. This results in complex interactions with service providers in education and health settings, impacting on outcomes for individuals and their families. This national study sought to gather the viewpoints of individuals who experience PDA, families, and practitioners, with the intention of determining levels of knowledge, recognition and understanding of PDA; exploring current pathways to assessment and diagnosis; capturing experiences of access to education and healthcare services; identifying effective intervention and support strategies; and illuminating education and health outcomes for individuals and families. This mixed‐method study collates survey responses from N = 264 parents, N = 9 life partners, N = 6 individuals experiencing PDA and N = 54 practitioners, and in‐depth individual and focus group interviews from these cohorts. Findings suggest that a flexible, informed and individualised approach to assessment and service provision for individuals presenting with a PDA profile is essential. Practitioners universally referred to the necessity for a streamlined, integrated and multi‐disciplinary approach. The reported disconnect between education and health systems indicates a need for access to services on an equitable basis.

The forensic implications of camouflaging: a study into victimisation and offending associated with autism and pathological demand avoidance

PurposeThis study aims to investigate the influence of social camouflaging on victimisation and offending in relation to autism and pathological demand avoidance (PDA) traits. Camouflaging aims to overcome or conceal difficulties in social and communication skills. Autistic individuals report camouflaging in response to threat and being verbally and physically assaulted when they have not camouflaged. Thus, camouflaging could be associated with victimisation. Camouflaging could also impact on specialist support available to an individual, potentially increasing the risk of victimisation or offending.Design/methodology/approachCross-sectional study was conducted using 220 participants from the general population who completed online questionnaires measuring victimisation and offending, autism and PDA traits, camouflaging and symptoms of depression and anxiety.FindingsCorrelational analysis found positive associations between camouflaging and victimisation, and camouflaging and lifetime offending. Greater camouflaging and PDA traits predicted greater offending, whereas greater autism traits predicted fewer offending behaviours. While correlated, camouflaging was not significantly predictive of victimisation. Victimisation was predicted by symptoms of depression and PDA traits.Originality/valueTo the best of the authors’ knowledge, this study is the first to consider camouflaging as an influencing factor on offending and victimisation in autistic and PDA individuals.

Diagnostische validiteit van het concept Pathological Demand Avoidance: een systematische literatuurreview

Title: Diagnostic validity of the concept Pathological Demand Avoidance: a systematic review Background: Much is to be discussed about the evidence, positioning and usefulness of the concept Pathological Demand Avoidance (PDA). The concept of PDA envelopes a behavioural pattern of resistance to meet ordinary demands of life and the usage of manipulative strategies in order to achieve this; a superficial sociability, lability of mood, obsessive behaviour and fallback into role play as a coping strategy. Until now, the validity of this concept has not been systematically reviewed. Method: This review researches the different aspects of validity based on the five phases by Robins and Guze and a supplementary section about treatment guidelines. A systematic search has been conducted to find relevant studies concerning the validity of PDA using the following databases: Pubmed, Embase, Medline, Cochrane Library, Web of Science and Google Scholar. Full articles with a study design or case reports, published in a peer-reviewed journal were included. Results: 12 relevant study designs and 6 case reports were found. Regarding the two common symptomatic descriptions of PDA no operationalization nor cluster analytic studies were found. Two PDA-related measurement instruments are described. They demonstrated a good internal consistency, but are not validated by research in an independent clinical population. The PDA-dimension correlates with other dimensions of psychopathology (ASD, personality factors and ADHD). However, the positioning of PDA (within the Autism spectrum, as a combination of comorbid factors or as a unique diagnosis) remains unclear. Regarding other domains of validity, as regarding treatment response, insufficient conclusive research has been conducted. Conclusion: Insufficient arguments have been found in the current literature to perceive PDA as a valid concept. At first, cluster analytic studies about the symptoms need to be conducted. A valid definition and delineation regarding PDA is critical to conduct further research to other domains of validity.

Alternatives to Gold Standard Diagnostic Tools for Distinguishing “Natural Kinds” on the Autism Spectrum

Next-generation sequencing techniques have accelerated the discovery of rare mutations responsible for autism spectrum disorder (ASD) in genes involved in a large number of physiological processes, including the control of gene expression, chromatin remodeling, signaling pathways, synaptic scaffolding, neurotransmitter receptors, and lipid metabolism. Genetic diagnosis provides subjects with an explanation of the cause of their disorder. However, it does not, or at least does not yet, shed light on the psychopathological phenomena specific to the individual. It could be hypothesized that each physiological impact of a mutation corresponds to a specific psychopathological phenomenon of ASD, i.e., “a psychopathological natural kind”. We discuss here the difficulties identifying this specificity of underlying psychopathology in individuals with ASD due to a rare mutation with a major effect. A comparison of Newson's pathological demand avoidance and Wing's Asperger's syndrome with Asperger's autistic psychopathy highlights different ways of approaching psychopathological descriptions and diagnosis, by focusing on either common or unusual features. Such a comparison calls into question the principles of clinical research recommended by Falret for characterizing “disease individuality” of ASD due to a rare mutation.

It’s not Autism. It’s Your Parenting. An Autoethnographic Exploration of the Relationships Between Professionals and Parents of an Autistic Child in the UK

This paper is based on my own child who was diagnosed with Autism (aged 7 years and Autism and PDA aged 11). Using autoethnography, drawing on my own diaries, records and journals that I kept throughout this process, I document how our parenting was continually questioned and considered to be ineffective. This was the case even when our child had received his first diagnosis of autism. The extra stress and trauma that such continual questioning had impacted not only on us as parents, but also on our child with worsening behaviour. It seems that professionals continually questioned parenting styles, rather than focusing on the link between autism and behaviour, nor did they seem to understand the extreme stress and anxiety that parents and the autistic child themselves face. It was only when we started using strategies for Pathological Demand Avoidance (PDA) that our child’s behaviour improved although despite the casual remarks by the community paediatrician and other professionals that ‘it’s not PDA, it’s ineffectual parenting.’

Determinants of the evolutions of behaviours, school adjustment and quality of life in autistic children in an adapted school setting: an exploratory study with the International Classification of Functioning, disability and health (ICF).

BackgroundPrevious studies about Quality of Life (QoL) in autistic children (ASD) have put forward the negative impact of factors such as Autism Spectrum Disorder (ASD) severity, psychiatric comorbidities and adaptive behaviour impairment. However, little is known about the relation of these factors to school adjustment, measured with the International Classification of Functions disability and health (ICF) framework (World Health Organization, 2001), and QoL evolutions. Thus, this study aimed at investigating the determinants of behaviours, school adjustment and QoL changes in 32 children in an ASD inclusion program over one academic year.MethodsUsing Bayesian methods, we studied the impact of ASD severity, psychiatric comorbidities, adaptive behaviour level and a diagnosis of Pathological Demand Avoidance (PDA) on evolutions of behaviour, school adjustment (measured with the ICF) and QoL.ResultsAs predicted, adequate adaptive behaviour levels were associated with better progress of behaviours and school adjustment whereas psychiatric comorbidities were related to worse outcome of school adjustment. Contrary to our hypotheses, severe ASD was associated to better evolution of adjustment at school. PDA was not discriminant. We did not find any association between the studied factors and the evolution of QoL over the academic year.ConclusionOur results show that the assessment of adaptive behaviour levels, psychiatric comorbidities and ASD severity level may be useful predictors to discriminate of school adjustment evolution (assessed by teachers within the ICF model) over a one-year period in autistic children. The assessment of this time course of school adjustment was sensitive to change and adapted to differentiate evolutions in an inclusive education framework. The investigation of quality of school life of autistic children as well as its determinants may therefore be relevant to improving academic adaptation. However, further research in larger groups, over longer periods and in different personalized school settings for autistic children is needed.

Pathological demand avoidance in autism, explained

Pathological demand avoidance in autism, explained

Pathological demand avoidance in children and adolescents: A systematic review.

Requests for diagnoses of pathological demand avoidance have increased over recent years, but pathological demand avoidance remains a controversial issue. The concept of pathological demand avoidance has been criticised for undermining the self-advocacy of autistic people and neglecting the potential role of anxiety as a possible underlying or contributing cause. The current study was undertaken to summarise and review the methodological quality and findings from current research into pathological demand avoidance in children and adolescents. Further aims were to describe how pathological demand avoidance has been identified and to explore the relationships with autism and other developmental and psychiatric disorders. After a comprehensive search, 13 relevant studies using a wide range of methods were identified and systematic quality assessments were undertaken. All the studies had based the identification of pathological demand avoidance, directly or indirectly, on descriptions from the original study by Newson and colleagues. However, the methods used to develop these criteria were not clearly described. Most studies relied exclusively on parental report for data, and there was a general failure to take account of alternative explanations for the behaviours under study. No studies explored the views of individuals with pathological demand avoidance themselves. Problems concerning definition and measurement in the reviewed studies currently limit any conclusions regarding the uniformity or stability of the behaviours described, or the characteristics of individuals displaying them. Relationships between pathological demand avoidance and other emotional and behavioural difficulties should be explored in future research, as should the perspectives of individuals with pathological demand avoidance themselves.

The educational experiences of autistic children with and without extreme demand avoidance behaviours

ABSTRACT Extreme demand avoidance (EDA) is increasingly described as part of the autism spectrum and is sometimes diagnosed as Pathological Demand Avoidance (PDA). Yet little is known, about the educational experiences of children with and without EDA behaviours. Using an online survey collecting both quantitative and qualitative data, 211 parents reported on the school experiences of their autistic children. 57 parents had a child with an additional diagnosis of PDA (AUT-PDA); 91 had a child with no diagnosis of PDA but, according to parent report, displayed EDA behaviours (AUT-EDA); and 63 had a child with neither a PDA diagnosis nor EDA behaviours (AUT). Results demonstrated that there were few group differences in terms of the frequency of failed school placements and exclusions. However, children in the AUT-EDA/-PDA groups had higher levels of behaviour that challenges, which were particularly high in those with a PDA diagnosis. There were no significant differences in school exclusions, but the fact that these occurred across all groups is of concern. Qualitative results suggested overwhelmingly negative school experiences for all groups but especially the AUT-EDA and AUT-PDA groups. Parents attributed such experiences to misunderstanding of their children’s diagnoses and a lack of targeted support.

Pathological demand avoidance (PDA): Its four schools of thought

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.

Personality and pathological demand avoidance – identifying areas for future research

Pathological demand avoidance is a term first used by Elizabeth Newson in 1983, describing a pattern of behavioural traits found to be common amongst individuals with Autism Spectrum Disorders. Research has drawn comparisons between pathological demand avoidance and personality disorders, suggesting co-morbidity. This literature review identifies gaps in current research and highlights the debate about pathological demand avoidance as a subset of autism, or as a separate condition. More research is needed in this field to avoid misdiagnosis of this condition with personality disorders and to improve the educational provision for children with pathological demand avoidance in our schools.

Individual differences, ADHD, adult pathological demand avoidance, and delinquency

BackgroundPathological Demand Avoidance (PDA) is a developmental disorder involving challenging behaviour clinically linked to Autism Spectrum Disorder (ASD). Many of the problematic features of PDA are often seen in persons with attention deficit hyperactivity disorder and impulsivity. ADHD and impulsivity are also common in the backgrounds of offenders. AimsMethod and procedure: We examined if self-reported ASD, ADHD, impulsivity, and general personality traits such as low conscientiousness and low emotional stability predicted self-reported PDA scores, and which constructs contributed to the prediction of delinquency, recruiting 132 participants (mean age 34.6 years, SD = 10.9, range 18–68), of whom 126 cases had complete data. Outcomes and resultsMany of these constructs, but particularly ADHD (r = 0.71, p < 0.001) were significant correlates of PDA, the correlation between ASD and PDA was small, and did not predict PDA. Multiple regression indicated that a combination of higher attention deficit, antagonism, and lower emotional stability predicted 65 % of an individual’s PDA score, but that their PDA score did not contribute to the prediction of delinquency. Conclusions and ImplicationsThis research indicates that, for community adult populations, self-reported individual differences in ADHD, emotional instability, and antagonism appear to better predict PDA than ASD. The association PDA has with delinquency may reflect these constructs, which are also correlates of offending.

Dura-Vila and Levis' "Me and my PDA: A guide to pathological demand avoidance for young people" (book review)

Dura-Vila and Levis' "Me and my PDA: A guide to pathological demand avoidance for young people" (book review)

Commentary: Anxiety and behaviour in and beyond ASD; does the idea of 'PDA' really help? - a commentary on Stuart et al. (2020).

Many children with austism spectrum disorder (ASD) show difficulties containing anxiety, acute distress, behavioural avoidance or control, and sometimes to an extreme degree. Not nearly enough is known about the variety of likely origins of such presentations or their course. Pathological Demand Avoidance (PDA) has been advocated as a discrete developmental syndrome explaining such characteristics when extreme, but its status as an entity is controversial and to date poorly evidenced. Stuart et al. make one of the first studies into factors underlying PDA, by testing Intolerance of uncertainty and anxiety as explanatory paradigms. There is a circularity in their sampling design and common respondent methods, which, alongside the uncertain status of PDA itself, inevitably limits firm conclusions from their study. However, they do develop important concepts and hypotheses that could and should be tested in representative samples across ASD, using comparative, longitudinal and intervention designs. This will contribute to important progress will be made in understanding mental health presentations in ASD and their treatment, as well as resolving debates around PDA itself.

Pathological demand avoidance: What and who are being pathologised and in whose interests?

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.