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

Abstract

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. Key Practitioner Message• Children with ASD who resemble descriptions of extreme/'pathological' demand avoidance obsessively avoid complying with everyday demands, engage in apparently 'manipulative' behaviour and exhibit sudden changes in mood. We collected interview data from parents of children with ASD (parent-reported) and these features about their child's maladaptive behaviour.• Subtle differences emerged compared to previous accounts of this profile. These included additional problems relating to the child's frequent attempts to control situations and others' activities (e.g. by insisting that others abide by their rules or meet their demands). In our sample, avoidance behaviours could be described as 'strategic' rather than 'manipulative'. Parents perceived that a range of factors played a role in triggering extreme behaviour, including a negative emotional response to perceived pressure (in line with previous accounts), as well as sensory sensitivities, phobias and anxiety about the unknown.• These findings add to the literature on extreme noncompliance, mood variability and attempts to control situations and others' activities in ASD, and they motivate examination of similarities and...

The Measurement of Adult Pathological Demand Avoidance Traits

“…Behavioural non-compliance and emotional dysregulation is not exclusive to ASD, but have plausible drivers in the context of ASD [e.g. sensory sensitivities, phobias, need for predictability/sameness, perception of routine requests as aversive (Lucyshyn et al 2004 ; O’Nions et al 2018 )].…”

“…Recent work in individuals with ASD and problem behavior suggests a robust correlation between non-compliance with routine requests and irritability (Chowdhury et al 2016 ). Also differentiating ASD and PDA, there is some evidence to show individuals with PDA show good imagination and role-playing [although reports of observed behaviour suggest this often involves mimicking characters and stories rather than introducing novelty (O’Nions et al 2018 )]. A similar degree of obsessionality may also be present—although with a more social focus in individuals with the PDA phenotype relative to those with more ‘typical’ ASD (Newson et al 2003 ).…”

Commentary: PDA ‐ what's in a name? Dimensions of difficulty in children reported to have an ASD and features of extreme/pathological demand avoidance: a commentary on O'Nions et al. (2017)

“…Recent publications by Happe and colleagues have renewed an interest in PDA among parents and professionals involved with autism. In their earlier publications and in the paper in this issue (O'Nions et al, 2018), they explore PDA features in autism; but they have described these features also in children with a wider range of neurodevelopmental and behaviour problems (O'Nions, Viding, Greven, Ronald, &Happ e, 2014 andO'Nions et al, 2016).…”

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

“…Once anxiety or aversion have been triggered by demands, parents report that increasing pressure on the child to comply can precipitate more severe forms of problem behaviour (e.g. threats, meltdowns, destructive behaviour, harm to self and others; Newson et al., ; O'Nions et al., ). This is in line with other work with children with developmental disabilities, which describes distress, arousal and attempts to physically escape from demand contexts (Lucyshyn et al., ).…”

“…Once these emotions are primed, behaviours that are successful in delaying or terminating demands would be reinforced. This may contribute to the emergence of an avoidance repertoire, including distraction, diversion and excuses (Newson, Le Maréchal, & David, ; O'Nions et al., ). The reduction in anxiety resulting from successful escape of demands could act to reinforce these behaviours, which may over time become habitual responses automatically cued by actual or perceived demands.…”