Intolerance of uncertainty and anxiety as explanatory frameworks for extreme demand avoidance in children and adolescents

Abstract

BackgroundPathological 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.MethodsIn 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.ResultsRegression 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.ConclusionsThis 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.

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

“…According to their parents, the AUT-PDA group displayed more behaviour that challenges during their most difficult term at school than autistic children without a PDA diagnosis (irrespective of their levels of EDA behaviours). Stuart et al (2020) identified behaviour that challenges such as aggression, as a 'last resort' behavioural response to uncertainty. It is possible that autistic children with an additional PDA diagnosis are responding with aggression when other attempts to reduce uncertainty and control their environment have failed.…”

Selective Mutism and Its Relations to Social Anxiety Disorder and Autism Spectrum Disorder

“…Interestingly, children with ASD score significantly higher on intolerance of uncertainty than typically developing children (Boulter et al 2014 ; Vasa et al 2018 ). This is one reason why this factor has been put forward as an important cognitive mechanism behind the anxiety symptoms and in its wake pathological demand avoidance (i.e., the obsessional avoidance of the demands of everyday life; Newson et al 2003 ) of children with this neurodevelopmental disorder (Maisel et al 2016 ; Stuart et al 2020 ).…”

Extreme Demand Avoidance in Children with Autism Spectrum Disorder: Refinement of a Caregiver-Report Measure

“…"Pathological demand avoidance" (PDA) was coined in the 1980s to describe a profile seen in some children on the autism spectrum/with autistic features characterized by obsessive resistance to everyday requests, plus strategic or "socially manipulative" behavior to avoid (Newson, 1983;Newson et al, 2003). Routine requests triggered attempts to distract, elaborate excuses, negotiation, or withdrawal, which could escalate into threats, aggression, destructive behavior, or self-harm if pursued (Eaton & Weaver, 2020;Newson et al, 2003;O'Nions et al, 2018a, b;Stuart et al, 2019). Newson et al (2003) argued that these behaviors did not reflect willful defiance, and suggested that the extreme response to demands was best construed as a panic attack.…”

“…It has been argued that PDA should be viewed as a collection of symptoms rather than a syndrome (Green et al, 2018). However, there is emerging consensus that some children with ASD do present with a behavioral profile resembling PDA, evidenced by work from several independent groups (Eaton & Banting, 2013;Eaton & Weaver, 2020;Gillberg et al, 2015;Green et al, 2018;O'Nions et al, 2018a, b;Stuart et al, 2019), and international scholars who report that some children with ASD find routine demands aversive and may react to pressure to comply with avoidance and behavior that challenges (e.g., Agazzi et al, 2013;Lucyshyn et al, 2004Lucyshyn et al, , 2007.…”