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Demand avoidance phenomena: circularity, integrity and validity – a commentary on the 2018 National Autistic Society PDA Conference
28 GAP,20,2, 2019
Demand avoidance phenomena: circularity, integrity and validity – a commentary on the 2018 National Autistic Society PDA Conference
Address for
correspondence
E-mail:
richardwoodsautism@
gmail.com
Acknowledgements
The author thanks
James Donovan, Lianne
Lawrence and Dr
Damian Milton for sup-
port in the production of
this article. I am grateful
to Dr Glenys Jones for
her helpful edits and
suggestions that much
improved the piece.
Psychologist (Newson et al, 2003). She ran assessment
clinics for children thought to be autistic. Among the chil-
dren referred, she felt that some had features in common
with autism but had other features that were not.
What is Demand Avoidance Phenomena?
Demand Avoidance Phenomena (DAP), otherwise
known as Pathological Demand Avoidance (PDA) was
rst suggested in 1980 in the United Kingdom (UK)
by Professor Elizabeth Newson, a Consultant Child
Demand avoidance phenomena:
circularity, integrity and validity
– a commentary on the 2018
National Autistic Society PDA
Conference
Richard Woods, Nottingham, UK
Editorial comment
There has been much discussion and debate on Pathological Demand Avoidance (PDA)
since it was rst described by Professor Elizabeth Newson in the UK in the 1980s. Is
it part of the autism spectrum or a separate condition or can the features of PDA be
found in other developmental conditions? If PDA can be separately dened, do the
origins or underlying causes of PDA differ from other conditions and, if so, what are the
implications?
The main consensus at present is that some autistic children and adults also have PDA
and that where this is true, different strategies are needed (Christie et al, 2011). But PDA
proles have been found in people with other conditions too (Egan et al, 2019; Kaushik
et al, 2015). There are some who assert that, as yet, there is insufcient evidence to
determine the criteria for PDA and its classication.
Some autistic individuals have referred to PDA as rational demand avoidance where
demands which are perceived to be aversive or illogical are avoided. Given that many
autistic individuals show demand avoidant behaviour, there is a concern that without clear
criteria for PDA, parents and professionals alike might assume that a person has both
autism and PDA and then seek further assessment or follow recommended strategies
for PDA which might not be useful or needed. So an ethical debate on PDA is needed.
In this paper, Richard Woods, an autistic academic, presents his views on PDA or, in his
words, the Demand Avoidance Phenomena.
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I accept the case put forward that DAPers and their
carers need appropriate support (Russell, 2018).
Unpublished research indicates DAP carers have
higher anxiety levels compared to carers of autism and
Conduct Disorder (Durà-Vilà and Levi, 2018), thus DAP
carers are a vulnerable group. Ethically, researchers
should take a balanced perspective on a topic (Brooks
et al, 2014). There is little ethical justication for refer-
ring to DAP with a term that reies it, like Pathological
Demand Avoidance.
DAP behaviour profile
Over the last few years Newson’s original behaviour
prole has been joined by two new DAP proles that
have been put forward by the National Autistic Society
and the PDA Society respectively. Aggregating the cri-
teria, DAP has ten diagnostic criteria, with six essential
for a diagnosis. These are:
comfortable in role play and pretend
continues to resist and avoid ordinary
demands of life
demand avoidance can use social strategies
lability of mood and impulsive
obsessive behaviour that is often focused
on other people
surface sociability, but apparent lack of sense
of social identity, pride, or shame (Green et al
2018a; Thompson, 2019; Woods, 2019a)
The four optional traits include:
delayed speech development
neurological involvement
passive early history (Newson et al 2003)
sensory differences (Eaton et al 2018)
There is much continuing debate and controversy over
the medical nature of DAP, the dominant ontology
of DAP being an autism subtype (Woods, 2019a).
Recently, traits of DAP have been observed in the early
case studies written by Hans Asperger, who described
DAP, in short, is characterised by obsessive noncom-
pliance, distress and orid challenging and socially
inappropriate behaviour in children, adolescents and
adults (Egan et al, 2019). Some have proposed a
change in terminology from ‘pathological’ to ‘extreme’
demand avoidance. This is to reect the idea that, from
the individual’s perspective, avoidance of everyday
requests may seem appropriate and not ‘pathological’,
even though it is deemed disproportionate to others
(Gillberg, 2014). For others, the severity and extent of
the problem justies the term ‘pathological’.
Autistic authors have expressed that DAPers’ (those
identied with its prole) actions are inherently rational
from their lived experience and it should be called
Rational Demand Avoidance. This name would be
applicable to all persons diagnosed with DAP (Milton,
2017; Woods, 2019b). For example, DAPer Harry
Thompson frequently responded to dares or acted
outrageously to gain other people’s attention, as this
was the only way he could reliably predict how others
would react to him (Thompson, 2019). Such behaviour
is also seen in other diagnosed DAPers.
The extreme behaviours found in Oppositional Deant
Disorder are due to individuals attempting to maintain
social relations or social status (Stuart et al, 2019).
Moreover, individuals with Attachment Disorders may
nd negative behaviour gains more attention than
positive behaviour, and so expressing the former
reduces anxiety from their chaotic and unpredictable
worldview, so they engage in behaviours viewed
challenging by others (Pearce, 2017). One can then
view DAPers actions as belonging to either of these
two conditions.
For a myriad of reasons I transitioned to utilising DAP.
A pivotal factor is the substantial number of possible
explanations for DAP which will be discussed later in
the paper. There is no compelling empirical evidence
base to favour any proposed ontology over another
(Green et al, 2018a; Milton, 2017). Additionally, autis-
tic persons and DAPers are prone to internalising
(Eaton, 2017; Woods 2018a). DAP is promoted on
social media, mainly aimed at DAP carers (Green et
al, 2018a).
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30 GAP,20,2, 2019
The ontology of DAP
There is much continuing debate and controversy over
the medical nature of DAP, the dominant ontology
being an autism subtype (Woods, 2019a). In their
conclusions on a commentary paper on DAP in 2018,
Malik and Baird stated that there are many features
described in DAP which overlap with those found in
other classied mental and behavioural disorders
(Autism, Oppositional Deant Disorder, Conduct,
Anxiety/Mood Disorders) but that these may have a
different underlying basis. They maintained that more
descriptive research of traits across many disorders is
needed to clarify the criteria and distinctiveness of other
conditions, including DAP. Most, if not all, rely on sub-
jective judgements which lead to a lack of consensus
and diagnostic confusion. Agreement on constructs
such as noncompliance; demand avoidance; opposi-
tionality; social manipulation; emotional dysregulation
would be needed for this work.
Should DAP be viewed as part of the autism
spectrum?
Notable stakeholders, including those organising and
supporting the PDA conference hold this perspective,
ie parents, clinicians and charities (Green et al, 2018a).
However, as Tab le 1 highlights, DAP has numerous
competing claims for its medical ontology. Just under
three quarters (70 per cent) of autistic people have at
least one co-occurring psychiatric condition (Lai et al,
2014) and 41 per cent have multiple, additional comor-
bid conditions (Green et al, 2018a). Some disorders,
such as anxiety and depression, are prevalent in autism,
and so on the balance of probability, DAP is likely to
be among these co-occurring conditions (Green et al,
2018b). It is possible that DAP is frequently diagnosed
in autistic people because it is invariably interpreted as
a form of autism, as part of diagnostic overshadowing
(Fletcher-Watson and Happé, 2019).
A population study of DAP reported in 2015 suggests that
it may occur in one in ve of those with autism (Gillberg
et al, 2015). This prevalence rate is higher than that
observed by Elizabeth Newson and raises concerns as
to whether it is the same underlying condition being
observed (Woods, 2019a). However, this research was
conducted with an unvalidated Diagnostic Interview
some unexpected impulsive acts that were extremely
challenging for others to control (Falk, 2019; Sanchez,
2018). For example, Asperger noted of Fritz, V:
“the conduct disorders were particularly
gross when demands were made on him …
when one tried to give him something to do
or to teach something … it required great
skill to make him join some PE or work even
for a short while … it was particularly in
these situations that he would start jumping,
hitting, climbing … or some stereotyped
sing-song.” (Sanchez, 2018).
This suggests that there is no specicity to DAP. Despite
substantial debates occurring, this paper draws atten-
tion to multiple facets that are not reected in the main
DAP discourse.
Current interest in DAP in the UK
There is a growing interest in the UK in DAP, and much
lobbying by DAP supporters on social media (Green et
al, 2018). A number of professionals and parents have
also identied children who seem signicantly more
demand avoidant than autistic children and who do not
respond to the strategies usually recommended. As a
result of this increased interest, the National Autistic
Society now convenes an annual conference on the
subject. At the latest event in 2018, Phil Christie, a
Clinical Psychologist and close colleague of the late
Elizabeth Newson, and an advocate of DAP, said the
aim of the conference was:
“to build on developments, insights and
increasing recognition of PDA but maintain
the integrity of how the condition is
understood and the nature of support that is
needed by individuals.” (Christie, 2018).
The nature and understanding that Christie is referring
to above is that DAP is an autism subtype and that
DAPers require strategies different from other condi-
tions. This raises the question: is there validity or merit
to this statement?
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These studies indicate DAP has a high drop off rate in
persons meeting the clinical threshold for a diagnosis
into adulthood, between 44 to 89 per cent (Gillberg et
al, 2015; O’Nions et al, 2016). This is higher than that
found in autism. However, the studies discussed in this
paragraph have substantial limitations including being
circular in nature.
for Social and Communication Disorders (DISCO); see
O’Nions et al (2016) for the validated version. Happé and
her colleagues have explored DAP features in autism
and have identied these features also in children with
a wider range of neurodevelopmental and behaviour
problems (O’Nions et al, 2014; O’Nions et al, 2016). So
DAP features do not appear to be conned to autism.
Table 1: Demand Avoidance Phenomena: possible medical ontologies
Possible medical ontology Comorbid prevalence rates (%)
Autism Unable to source data
Autism subtype/ of form Pervasive Developmental Disorder Unable to source data
Autistic trauma Unable to source data
Female form of autism Unable to source data
Form of Attachment Disorder Unable to source data
Form of catatonia 12 –18% (Eaton, 2017)
Form of personality disorder 0 – 32% (Lai et al, 2014)
Heterogeneous Spectrum Condition Unable to source data
Symptoms of autism and Attention Decit Hyperactivity
Disorder (ADHD)
28% (Green et al 2018a)
Symptoms of autism and eating disorders 4 – 5% (Lai et al, 2014)
Symptoms of autism and anxiety 42 – 56% (Lai et al, 2014)
Symptoms of autism and anxiety disorders About 40% (Belardinelli et al, 2016;
Francisca et al, 2017)
Symptoms of autism and Depression 12 – 70% (Lai et al, 2014)
Symptoms of autism and Dyslexia Unable to source data
Symptoms of autism and Dyspraxia Unable to source data
Symptoms of Autism and Oppositional Deant Disorder (ODD) 28% (Green et al 2018a)
Symptom of Autism and Schizophrenia 0 – 6% (Chaplin 2017)
This table has been adapted from Woods (2018b), with the addition of dyslexia and dyspraxia from the National
Autistic Society webpage on DAP (National Autistic Society 2018). Jonathan Green and colleagues note that DAP
behaviours can be explained by an unrecognised learning impairment (2018b). The Gillberg et al (2015) 1 in 5
prevalence rates for DAP have not been included due to questions over their validity.
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32 GAP,20,2, 2019
of viewing that DAPers anxiety is intrinsically caused,
many think DAPers anxiety is extrinsically caused. The
opinion that DAP is entirely caused by genetic factors is
found in the DAP literature (Harvey, 2012). Rutter and
Pickles (2016) also highlight that diagnostic classica-
tion systems are not designed along biological lines
and that there is no evidence to justify adopting such an
approach. They went on to note that biomarker research
is unlikely to make any major breakthrough. Therefore,
DAP being entirely biological in nature cannot be tested
and can be viewed as pseudoscience. There is no con-
sensus on how DAP is understood (Eaton, 2017; Stuart
et al, 2019; Woods, 2019a). Subsequently, there are
numerous interpretations of how DAP is conceptualised.
The Autism Spectrum Disorder diagnosis has construct
validity (Green et al, 2018a). As a neurodiversity sup-
porter, I wish there to be good quality autism research
as recommended by Fletcher-Watson, (2019), Milton
(2017) and Waltz (2007). I contest the fact that DAP
is being diagnosed as an autism subtype. For it to be
accepted as an autism subtype, DAP requires an evi-
dence base that exceeds that Asperger syndrome’s in
both quality and quantity. Furthermore, understanding of
DAP is argued to be 30 years behind autism (Christie et
al, 2011). Autism used to be viewed as a form of schiz-
ophrenia (Loong, 2019). Long term, there is nothing to
prevent DAP’s nosology classication changing like
autism’s has done.
No consensus over DAP’s clinical profile
There are contradictions on precisely the criteria needed
for a DAP diagnosis, with three different behavioural
proles proposed (Newson et al, 2003; Eaton et al,
2018; Green et al, 2018a). At the PDA conference, many
speakers claimed that all eight criteria from Newson’s
diagnostic prole are compulsory for DAP identication.
However, since at least 2016, the developmental com-
ponents of delayed speech development, neurological
involvement and passive history have not been seen as
essential when making a DAP diagnosis (Green et al,
2018a; National Autistic Society, 2018; Sanchez, 2018).
One inuential study shows the best predictor for what
subtype a person is diagnosed with, is the clinic they
attended (Fletcher-Watson and Happé, 2019; Green et
Should DAP be regarded as a separate entity?
Describing a DAP behavioural prole is not evidence
that it exists as a separate entity (Woods, 2019a).
Various DAP behaviours might be explained using the
‘Vicious Flower’ analogy often used in treating anxiety
and depression (Moorey, 2010). The centre of the
ower contains the distressing emotion or an unhelpful
belief, and the surrounding petals are the vicious cycles
which maintain the central problem. The Vicious Flower
contains a cycle for demand avoidance as a part of
depression, including maintaining the condition (Moorey,
2010). Two studies that take an inductive approach to
DAP indicate that the construct behaviours are likely to
be caused by general psychopathy (Egan et al, 2019;
Green et al, 2018), with larger scale study indicating
many DAPers do not meet the case for autism (Kay,
2019). Therefore, providing tentative support for the view
that DAP extends beyond an autism subtype. This is not
surprising as most psychopathology conditions have a
signicant amount of overlap (Pickles and Rutter, 2016).
Some clinicians have observed that DAP is a broad
condition found in many clinical populations outside
of autism, such as Christopher Gillberg (2014). A
small scale study indicates DAP is found in those with
Conduct Disorder and ADHD (Kaushik et al, 2015). DAP
has no behavioural or cognitive trait unique to it, it has
no specicity (Christie et al, 2011; Garralda, 2003; Malik
and Baird, 2018; Wing, 2002). The pluripotential nature
of the DAP prole and the subjective symptoms means
that at present, many conditions might be identied
as DAP if one is looking for it (Woods, 2018a). It is
challenging to draw hard boundaries between DAP and
other conditions, so diagnosing DAP can easily lead to
confusion (Garralda, 2003; Green et al, 2018b).
Is DAP the result of a combination of autism and
other comorbidities?
A transactional approach has been offered to view
DAP as a mixture of autism and comorbidities (Fidler
and Christie, 2018; Green et al, 2018a; Milton, 2017).
Nonetheless, a prevailing outlook appears to be forming
among both DAP’s proponents and its critics, that it may
be an expression of autistic trauma (Eaton, 2018b; Milton,
2017), opposite to DAP originating from exclusively
biological and genetic factors (Christie, 2018). Instead
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quantitative differences were found between the three
groups (Eaton, 2018b). Demand avoidant behaviours as
measured on the EDA-Q (Extreme Demand Avoidance
Questionnaire, O’Nions et al, 2014) were found in all
three groups. The EDA-Q detected DAP behaviours in
all three groups, supported wider research of Egan et
al (2018), Green et al (2018a) and Kaushik et al (2015).
Not much at present can be taken from ndings such
as these as the clinic specialised in autism and so it
is likely that a narrower group of children would be
assessed than children seen in a generic child devel-
opment centre. For these results to carry weight they
would need to be replicated across at least several
sites and steps taken to ensure DAP diagnosis has
over 80 per cent reliability with the ADOS (Autism
Diagnostic Observation Schedule) across participating
clinics, showing construct validity that autism subtypes
currently lack (Green et al 2018a). The methodology
has numerous aws, including being circular as
DAPers were only identied if they rst matched autism
diagnostic criteria in Diagnostic and Statistical Manual
of Mental Disorders, 5th Edition (DSM5). Afterwards
potential DAPers were assessed against the original
Newson prole as this clinic only offers the Autism +
DAP Traits diagnosis. Their results can be explained
by diagnostic overshadowing (Fletcher-Watson and
Happé, 2019).
Eaton’s clinic published a DAP diagnostic prole based
on information from the PDA Society, with added notes
from their clinical observations (Eaton et al, 2018).
Nonetheless, the author has had conrmation that
Eaton and her clinic currently use a reduced Newson
DAP prole as found on the National Autistic Society’s
website. This prole lacks: delayed speech develop-
ment, passive early history and neurological involve-
ment, from Elizabeth Newson’s original prole (Green
et al, 2018a; National Autistic Society, 2018; Thompson,
2019); over the PDA Society’s prole. Eaton’s clinic
appears to have switched from utilising the full Newson
prole to its reduced version after they nished col-
lecting participants for this research. This matters as
there is no consensus on how to diagnose DAP and
the favoured relaxed behaviour prole means more
al 2018a) and autistic persons often transition between
subtypes (Wing, 2002; Wing et al, 2011; Woods, 2018a).
In addition, it is often impossible to mark the boundaries
between subtypes, with many autistic persons having
features of multiple subtypes. The challenges faced in
dividing autism subgroups is faced by all proposed sub-
types (Fletcher-Watson and Happé, 2019; Wing, 2002;
Wing et al, 2011), including DAP. Any behaviours or
traits that identify DAP as distinct from other conditions,
including non-DAPer autistics; would contradict our
current understandings of autism and indicate that DAP
is not a form of autism.
A study by Eaton and her colleagues to
explore the DAP profile in clinic referrals
Eaton and her colleagues made detailed assessments
of 351 children (aged from under 5 to over 17 years)
who were referred to their clinic over a two year period
(Eaton et al, 2018). From their data, they grouped the
children into three categories (see Tab le 2 ).
Table 2: Three diagnostic groups within the
sample referred
Diagnostic group Number Percentage
of sample
Autism 145 41
Autism and DAP 111 32
Neither Autism or DAP 95 27
Tot a l 351 100
Of the children 73 per cent were diagnosed with autism
and, of those, 43 per cent also had a DAP prole. All
those with DAP had autism and they concluded that the
children in the rst two groups had more in common
with each other than the third group. Qualitative and
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34 GAP,20,2, 2019
DAP strategies in wider discourses
A list of DAP strategies can be found in the Autism
Education Trust’s resources (Woods, 2019b):
A specic keyworker to build a trusted
relationship
Being exible and adaptable
Indirect praise
Letting things go
Negotiating by providing choices to pupils
Positive relations
Thinking aloud
Tone of voice
Treating anger as communication
Use humour
Use of role play, novelty and variety
of lesson material
Visual communication methods
Green et al (2018b) suggested a review of treatments
for autism may be benecial. Accordingly, I provide a
current list of comparable approaches and pedago-
gies to DAP strategies:
Autism catatonia strategies (Eaton 2017)
Autistic preferred approaches
(Laurent 2019; Milton 2018)
Capabilities approach (Woods, 2019b)
Dialectical Behaviour Therapy
(Eaton, 2017; Eaton, 2018a; Fieldman, 2018)
Evidence based practices (Green et al 2018b)
Inquiries based learning
Low Arousal Approach (McDonnell, 2019)
SPELL – Structure, Positive (approaches and
expectations), Empathy, Low Arousal and Links
Framework developed by the NAS (Milton 2017)
Universal Design for Learning (Woods, 2019b)
persons are eligible for a DAP diagnosis than the par-
ticipants in this research. Therefore, this research lacks
external validity. Future validation studies investigating
general population and non autistic groups are required
to provide meaningful information on the construct.
Non-medical explanations of DAP
DAP is a behaviourist approach to autism (Milton, 2017).
Lorna Wing in her critique of DAP, noted that DAPers
appear to gain reward from upsetting others (2002).
O’Nions et al (2018) argue DAPers can be conditioned
into the prole by nding demands aversive, indicating
DAPers can be conditioned. The DAP strategies are
to be practised all the time (Christie et al, 2011; Fidler
and Christie, 2018; Woods 2018a); comparable to the
amount of time suggested for behaviourist interventions.
There are examples of DAPers receiving bribes and
signicant rewards after displaying demand avoidance
behaviour (Woods 2018a).
Unpublished research by Sarah Potts investigating
DAP and personality disorders, indicates there are
differences between DAP and personality disorders,
although this study appears to suffer from signicant
limitations. Applicable results from Sarah Potts’ study,
that contribute to the debate about DAPers being
conditioned into the prole include: rst, being inclined
to break rules for personal prot; secondly, that they
are motivated by material gain. Collectively, these
factors lend credence that DAPers are conditioned into
aspects of the prole.
It is acknowledged DAP can be explained by an
Interest Based Account of autism – monotropism theory
(Eaton, 2018). Nevertheless, the theory views demand
avoidance as inherently rational (Woods, 2018b). Also,
DAP behaviours can largely be explained as a result of
stigma (Woods, 2018a). Signifying, Christie’s statement
is an arbitrary line in the sand (Milton, 2017).
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GAP,20,2, 2019 35
is benecial to all persons (Loong, 2019), deperson-
alising requests to appear as not a demand. Gore
and colleagues (2019) in a series of interviews with
12 autism carers found that when parents take a rigid
approach, placing many demands when an autistic
person is displaying distress behaviours, this escalates
such behaviours and decreases the chance of positive
practices.
O’Hare (2019) writing on behalf of the British
Psychological Society’ Division of Educational and
Child Psychology notes that simplistic and reactive ap-
proaches are stressful to teachers and do not adequate-
ly teach children why their behaviours should change.
The latter point is essential when working with a demo-
graphic known for experiencing social problems, such
as autistic persons and DAPers. Furthermore, O’Hare
also states:
“Warm supportive relationships with adults, a
sense of belonging, high expectations, teaching
social-emotional skills and autonomy are the
key ‘ingredients’ to positive behaviour change for
children and young people.” (O’Hare, 2019).
This is reective of the DAP strategies, for instance utilising
humour. Autistic people frequently have a vibrant sense
of humour (Bertilsdotter-Rosqvist, 2012). Qualitative
research indicates that autistic pupils become more
‘functional’ when working with their (special/intense)
interests (Wood, 2019). Building trusting relations is an
attachment disorder approach (Pearce, 2017). Leeds
City has reduced childhood obesity, partly by using an
approach where carers provide the child with a choice
of food options (Boseley, 2019).
It is clear that placing any human in a position of control
is probably benecial to them. Thus, underlying the
points made by Andy McDonnell (2019), and illustrat-
ing how the DAP strategies replicate good practice.
Additionally, this point is underlined by the Positive
(Approach and Expectations) aspect of the SPELL
Framework, which mirrors the part of the Special edu-
cational needs and disability (SEND) Code of Practice,
where SEND persons are to be encouraged to reach
Eaton has noticed the similarities between Borderline
Personality Disorder (BPD) and DAP, noting those
individuals diagnosed with both constructs display
demand avoidance or escape behaviours (Eaton,
2017). Subsequently, she used BPD’s strategies of
Dialectical Behaviour Therapy (DBT) with her DAPer’s
and says it can be effective (Eaton, 2017; Eaton,
2018a). The current approach to DAP nosology is
that it has strategies that are different to non DAPers;
this is an atypical nosology (Green et al, 2018b).
Following the logic for DAP nosology through, due
to its strategies overlapping those for catatonia and
BPD, DAP can be seen as either a form of catatonia
or personality disorder. I will next explore how DAP
strategies are generic good practice.
It is often mentioned that DAPers do not benet from
routines, compared to autistic persons. However, a
more thorough investigation of the literature contradicts
this. Elizabeth Newson noted in her research that 60
per cent of DAPers adhered to routines (Newson and
Le Merechal, 1998). Moreover, recent resource books
state DAPers can benet from routines the DAPers
themselves choose (Dura-Vila and Levi, 2018; Fidler
and Christie, 2018). For general autism strategies, the
SPELL Framework is comparable to DAP strategies;
for instance, the structure aspect is about removing
structures that are barriers to inclusion, for instance
removing any routines that increase autistic persons’
stress (anxiety). Structures that promote autonomy
should be included (Milton 2017). One can conclude
that both DAPers and individuals with autism gain from
routines of their choosing.
Autistic authors argue that DAP approaches are suit-
able for many persons (Milton, 2017; Woods, 2019a).
Similar evidenced based strategies have been used
for years with autism independent of the DAP construct
(Green et al, 2018b). In his guide to a Low Arousal
Approach, Andy McDonnell describes how around two
thirds of distress behaviour (challenging behaviour) is
triggered by requests or demands by other persons
and how all persons benet from having a sense of
control (McDonnell, 2019). This can explain why Oralie
Loong anecdotally observed that declarative language
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36 GAP, 20,2, 2019
The results show:
the primary DAP discourse is being
challenged
key literature is being accessed thousands
of times
key literature rarely references critical
literature, except to support its case
or disagree with critique
a lack of autistic perspectives referenced
a community of practice forming
There are various reasons why these matter to practice,
particularly the implication it is a community of practice.
Firstly, the main DAP discourse lacks the evidence to
justify its claims. Community of practices form their
own ideology (Milton, 2017). For DAP’s main discourse
it is that DAP is an autism subtype with its own unique
strategies. This means the lack of supporting evidence
for their claims is not being sufciently challenged
internally within the main discourse, as DAP is reied
as Pathological Demand Avoidance. Most concerning,
are the potentially negligent assumptions forming within
the main DAP discourse; for instance, it is argued that
the DAPers’ behaviours are not caused by their parents
(Durà-Vilà, and Levi, 2018). However, there is inade-
quate evidence to justify this (Milton, 2017).
Resulting from its individual ideology, the main DAP
literature is creating its own terminology, such as ‘more
straight forward autism’ (Fidler and Christie, 2018) and
‘atypical autism’ (Durà-Vilà and Levi, 2018; Thompson,
2018). Such terms are problematic for various reasons.
‘Atypical autism’ is nonsense as we know that autism
subtypes do not hold up clinically (Sanchez, 2018);
such differences between autism subtypes are
basically subjective and do not stand up to empirical
testing. ‘More straight forward autism’ ignores the large
body of evidence indicating that autistic persons are
systematically failed by society. This is acknowledged
within DAP scholarship as all autistic pupils appear
to be struggling to access appropriate educational
support (Kay, 2019). Other examples can be found
in Woods (2017b). A signicant report by the All Party
their potential and to be independent. This is a deciding
factor in why some view DAP as a redundant clinical
construct (Green et al, 2018b). An additional diagnostic
label that exists to access approaches that replicate
good practice requires substantial ethical justication.
DAP citation survey
A lack of debate
There are concerns over silencing divergent opinion to
the main on DAP (Woods, 2018a). Discourse maintains
that it is an autism subtype and has its own unique
strategies. Its leading proponents frequently argue
that debating DAP is a distraction from diagnosing it
(Christie, 2007; Christie et al, 2011; Fidler and Christie,
2018). Elizabeth Newson and colleagues argued
in their original paper that DAP is needed to benet
parents (2003). The ‘lightbulb moment’ is when a
person (typically a carer) has strong resonance (recog-
nition) upon initially encountering information of the DAP
prole. More recently, the lightbulb moment is a vital
justication to support the dominant discourse (Christie
et al, 2011; Fidler and Christie, 2018; Russell, 2018).
This central tenet to the main DAP discourse, that it
is required for the benet of parents, is pivotal to the
bias to maintaining the integrity of the DAP discourse.
It means that the supporters of DAP’s main discourse
appear closed to the DAP construct evolving away from
being an autism subtype (PDA Society, 2018). It must
be noted that much DAP research is coordinated by the
PDA Development Group that is headed by Phil Christie.
Researchers are required to be open minded, to avoid
research “designed to support a preconceived notion
or belief” (Chown et al, 2019, p1). Ethically, researchers
need to attempt falsication of their hypothesis as part
of the scientic method that is involved in most research
(Milton, 2016; Rutter and Pickles, 2016). Therefore, it
appears that the main DAP discourse is self validating
pseudoscience.
Citation survey results
Investigating these concerns, I conducted a citation
survey to explore whether the literature conforming to
the dominant DAP discourse is forming a community of
practice (the methodology, results and discussion are
available from the author).
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Demand avoidance phenomena: circularity, integrity and validity – a commentary on the 2018 National Autistic Society PDA Conference
GAP,20,2, 2019 37
recognising it as an autism subtype. An ethical debate
on DAP is required to establish a consensus on how to
approach the construct.
To conclude, there is little or no validity to justify
Christie’s conference statement to maintain the domi-
nant perspective’s integrity and understanding of DAP.
Attempting to do so, in itself, could cause confusion
over the conicted nature of DAP (Garralda, 2003;
Green et al, 2018a). Future research, taking a scien-
tic, non circular method based approach to DAP is
required for DAP to meet evidence thresholds for its
acceptance. Pertinently, policy and practice require
such evidence (Fletcher-Watson and Happé, 2019).
Finally, in everyday practice, all stakeholders should
follow the recommendations of Green et al (2018a), or
treat DAP as an undened, non-autism comorbid.
Parliamentary Group on Autism shows many indicators
of quality of service are decreasing and also notes
the lack of funds available to local government (2019).
Some carers are using DAP as a proxy to access better
support strategies (Green et al, 2018b). This demand
for the construct is partly driven by austerity measures
(Woods, 2018a). Stepping into this gap in support,
some private clinics have emerged diagnosing DAP
and this is contributing to the commodication of autism
through DAP (Woods 2017a).
Within the DAP literature it acknowledges that all autistic
persons should be treated as individuals to receive
bespoke approaches (Christie, 2007). There is no one
size ts all approach to autism because there are no
straightforward autistic persons for such an approach
to be effective with. The language around the main DAP
discourse leads to sources of possible conrmation bias.
O’Nions et al (2016) note that the ongoing campaigning
can lead people to be “on the lookout” for features of
DAP. Consequently, along with omitting autistic per-
spectives, these undermine the ethical and epistemic
integrity of the main DAP literature and its supporting
research (Milton, 2017). It is worth noting that the DAP
literature base is tiny and with the current UK climate of
participatory research, there is no excuse for excluding
autistic scholarship from the DAP literature, especially if
one perceives DAP as a form of autism.
Concluding comments
This paper provides an array of provocations to stim-
ulate debate on DAP. Initially detailing how DAP has
no specicity and a large number of possible medical
explanations to the prole. Compellingly, there are a
signicant number of common autism comorbidities
which can explain the DAP through interacting with
autism. I critically engage with ongoing research from
Eaton’s clinic, indicating it lacks external validity as its
sample is not representative. I contextualise DAP strat-
egies in wider discourses, drawing attention to how
they replicate good practice found elsewhere. Finally,
I explain the key ndings from a citation survey and its
implications for the DAP debate. DAP literature needs
to be situated in wider discourses; in the process under-
lining why the circularity surrounding the DAP construct
needs to stop and so move away from the agenda of
GAP_text_Autumn_2019.indd 37 30/10/2019 12:15
Demand avoidance phenomena: circularity, integrity and validity – a commentary on the 2018 National Autistic Society PDA Conference
38 GAP, 20,2, 2019
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