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DAP at lower diagnostic thresholds rationale in 15 minutes. 1
Demand Avoidance Phenomena (“Pathological”/
“Extreme” Demand Avoidance): is it a Disorder at a lower
diagnostic threshold?
Mr. Richard Woods.
London South Bank University PhD Student.
20th of July 2021.
DAP at lower diagnostic thresholds rationale in 15 minutes. 2
IN THE BEGINNING.
Introduction.
1) “DAP is an ASD” outlook.
2) Four main schools of thought on DAP.
3) Autism history & DAP.
4) EDA-Q & literature.
5) “Pathological Demand Avoidance”.
DAP at lower diagnostic thresholds rationale in 15 minutes. 3
LET’S TALK.
Main DAP Discourse.
1) Called “Pathological Demand Avoidance” or “Extreme Demand
Avoidance”.
2) Originally a Pervasive Developmental Disorder.
3) A rare autism profile/ subgroup/ subtype.
4) Has unique strategies that are different to autism.
DAP at lower diagnostic thresholds rationale in 15 minutes. 4
LET’S TALK.
Main DAP Discourse, or not.
1) Debating what DAP could be, distracts from purpose of
diagnosing DAP, as an ASD (Christie 2007; Christie et al 2012;
Fidler & Christie 2019).
2) “…maintain the integrity of how the condition is understood…”
(Christie 2016; Christie 2018; Christie 2019).
3) Community of practice around main discourse (Woods 2019a).
4) Should we be debating what PDA could be? Should we be
researching divergent outlooks?
DAP at lower diagnostic thresholds rationale in 15 minutes. 5
LET’S TALK.
Main DAP Discourse.
1) 4 schools of thought:
- Common mental health disorder.
- Rare autism subtype.
- Rebranded autism.
- Symptoms from interaction between autism & co occurring
conditions.
2) I have a COI due to advocating for DAP as a common disorder &
earning an income from DAP training.
DAP at lower diagnostic thresholds rationale in 15 minutes. 6
SPIKY PROFILE.
Pseudo-syndrome DAP & its constituent conditions.
DAP at lower diagnostic thresholds rationale in 15 minutes. 7
TIME TO PROFILE YOU.
DAP at lower diagnostic thresholds rationale in 15 minutes. 8
TIME TO PROFILE YOU.
Core DAP Traits.
Anxiety
-
based Restricted & Repetitive Behaviours &
Interests (RRBIs):
Universal.
Avoidance of everyday demands.
Yes
Comfortable in role play & pretence.
No
Consistent mood swings & impulsivity.
No
Frequent & intense actions.
Yes
Social avoidance behaviours.
Yes
Universality of features is based on Newson et al (2003) statistics.
DAP at lower diagnostic thresholds rationale in 15 minutes. 9
A STRESSFUL SITUATION.
How are demands avoided. (PDA Society, 2020, p7).
DAP at lower diagnostic thresholds rationale in 15 minutes. 10
A STRESSFUL SITUATION.
Demand Management Cycle.
DAP at lower diagnostic thresholds rationale in 15 minutes. 11
A NOVEL ROLEPLAY.
What does a modern Disorder look like?
1) Are heterogenous in nature, with porous boundaries.
2) Most have features overlapping with other Disorders & are
spectrum in nature.
3) May have conflicting evidence for which diagnostic groupings
best fit; e.g., ADHD & disruptive, impulse-control, & conduct
disorders, instead of neurodevelopmental disorders.
4) No longer sensible to strive for homogeneous subtypes within
Disorders (APA 2013).
5) "the disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas
of functioning.“ (APA 2013, p21).
DAP at lower diagnostic thresholds rationale in 15 minutes. 12
AN OLD ROLEPLAY.
Autism history implications for DAP.
1) DAP history is compared to autism (Christie et al 2012).
2) Autism used to be a form of schizophrenia (Woods 2019a).
3) 1966 prevalence rates 1 in 2500, now ~ 1 in 100, can be higher.
4) Autism broadened into a spectrum (Happé & Frith 2020).
5) DSM4: PDD-NOS was the most commonly diagnosed subtype.
6) ASD Level One to Level Three (APA 2013).
7) “High Functioning Autism”, equivalent to Asperger’s.
8) Now accepted indistinguishable clinical differences & strategies
between autism subtypes (Woods 2020).
9) Confirms DAP can change diagnostic groupings & may be
substantially broadened.
DAP at lower diagnostic thresholds rationale in 15 minutes. 13
A MISMATCH OF SALIENCE?
Pervasive
Developmental
Coding Disorders
(Newson 1989;
1996).
DAP at lower diagnostic thresholds rationale in 15 minutes. 14
AN OLD ROLEPLAY.
DAP’s parallels with autism history.
1) Initial researcher/ clinician stated DAP is not an ASD (Newson
et al 2003).
2) “Over the course of the research I encountered children who
manifested much less marked presentations than those Newson
described, and typified a number of participants; but whose
parents or teachers identified PDA features in them.” (O’Nions
2013, p203).
3) Proposed as a common & new disorder (Gillberg 2014).
DAP at lower diagnostic thresholds rationale in 15 minutes. 15
AN OLD ROLEPLAY.
DAP’s parallels with autism history.
1) Studies DAP is seen outside of autism (Absoud 2019; Eaton
2018; Egan et al 2019; Flackhill et al 2017; Newson et al 2003;
O’Nions et al 2014a; O’Nions et al 2014b; O’Nions et al 2015;
O’Nions et al 2016; Reilly et al 2014).
2) Studies probably contain non-autistic persons (Stuart et al
2020; Trundle et al 2017).
3) Experts DAP is seen outside of autism (Green et al 2018; Woods
2020).
DAP at lower diagnostic thresholds rationale in 15 minutes. 16
AVOIDING VARIANCE.
EDA-Q is important.
1) A 26-item observer rated screening tool designed for use with
autistic CYP with DAP traits (O’Nions et al 2014a).
2) Validation study contained non-autistic CYP…
3) EDA-Q threshold is not pervasive or developmental (Woods
2021).
4) Most/ much DAP clinical needs arguments applicable lower
diagnostic thresholds (Woods 2021).
5) EDA-Q commonly used in DAP diagnoses (Lyle & Leatherland
2018; Reilly et al 2014; Summerhill & Collett 2018).
DAP at lower diagnostic thresholds rationale in 15 minutes. 17
AVOIDING VARIANCE.
EDA-Q is important.
1) EDA-Q is involved in most DAP research (Bishop 2018; Brede et
al 2017; Eaton 2018; Egan et al 2019; Goodman 2018; Green et
al 2018; Langton & Frederickson 2016a; Langton & Frederickson
2016b; Lyle & Leatherland 2018; Moore 2020; O’Nions et al
2014a, O’Nions 2015; O’Nions et al 2016; O’Nions et al 2018a;
O’Nions et al 2021; Reilly et al, 2014; Stuart et al, 2020;
Tollerfield et al 2021; Truman et al 2021; Woods 2019b).
2) Unwise to substantially deviate from its threshold.
DAP at lower diagnostic thresholds rationale in 15 minutes. 18
AVOIDING VARIANCE.
When does DAP become “Pathological Demand Avoidance”?
1) DAP presents as a continuum in human population.
2) Fluid & transient over lifespan & diverse situations.
3) "the disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas
of functioning.“ (APA 2013, p21).
4) “…start to display avoidant behaviour and challenging
behaviour in response to a particular stressor…” (Eaton 2018,
p20).
5) Around EDA-Q threshold and/ or “problematic demand
avoidance” (O’Nions et al 2018b).
DAP at lower diagnostic thresholds rationale in 15 minutes. 19
STRATEGIC SOCIAL AVOIDANCE BEHAVIOURS.
Going forward.
1) Respect autistic persons wishes not to divide autism (Fletcher-
Watson & Happé 2019; Kapp & Ne’eman 2019).
2) DAP is not autism.
3) Non-autistic persons with DAP have equal rights to diagnoses,
research & support.
4) Systematically investigate different outlooks on DAP, such as
can DAP be viewed as an Attachment Disorder, or a Personality
Disorder (Christie 2007)?
5) Please take part in my PhD studies.
DAP at lower diagnostic thresholds rationale in 15 minutes. 21
FIRST JOB REFERENCES.
References.
1) Absoud, M. (2019). Pathological Demand Avoidance: Clinic prevalence and characteristics (Conference
proceedings). Retrieved from: https://www.pdasociety.org.uk/wp-content/uploads/2019/09/Research-Meeting-
Report.pdf (Accessed 19 June 2021).
2) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
Washington, DC, American Psychiatric Association.
3) Bishop, E. (2018). The Relationship between Theory of Mind and Traits Associated with Autism Spectrum
Condition and Pathological Demand Avoidance Presentations. Doctorate of Clinical Psychology, University College
London.
4) Brede, J., Remington, A., Kenny, L., & Warren, K. (2017). Excluded from school: Autistic students’ experiences of
school exclusion and subsequent re-integration into school. Autism & Developmental Language Impairments,
2(1), 1-20.
5) Christie, P. (2007). The distinctive clinical and educational needs of children with pathological demand avoidance
syndrome: guidelines for good practice. Good Autism Practice, 8(1), 3–11.
6) Christie, P. (2016). Towards a better understanding of Pathological Demand Avoidance (Conference paper).
Retrieved from: https://www.dp.dk/decentrale-enheder/dansk-psykolog-forenings-selskab-for-
borneneuropsykologi/wp-content/uploads/sites/29/2016/04/Towards-an-Understanding...Denmark-Nov-2016.pdf
(Accessed 19 June 2021).
7) Christie, P. (2018). Towards a better understanding of Pathological Demand Avoidance. In: National Autistic
Society (Ed), Pathological Demand Avoidance Conference. London: National Autistic Society.
DAP at lower diagnostic thresholds rationale in 15 minutes. 22
SECOND JOB REFERENCES.
References.
1) Christie, P. (2019). Towards an understanding of Pathological Demand Avoidance (PDA): clinical, research and
educational perspectives. In: National Autistic Society (Ed), Pathological Demand Avoidance Conference. London:
National Autistic Society.
2) Christie, P., Duncan, M., Fidler, R., & Healey, Z. (2012). Understanding pathological demand avoidance syndrome
in children: A guide for parents, teachers and other professionals. London: Jessica Kingsley Publishers.
3) Eaton, J. (2018). PDA and differential diagnosis. In: National Autistic Society (Ed), Pathological Demand
Avoidance Conference. London: National Autistic Society.
4) Egan, V., Linenburg, O., & O’Nions, L. (2019). The Measurement of Adult Pathological Demand Avoidance Traits.
Journal of Autism and Developmental Disorders, 49(2), 481-494.
5) Fidler, R and Christie, P. (2019). Collaborative Approaches to Learning for Pupils with PDA: Strategies for
Education Professionals. London: Jessica Kingsley Publishers.
6) Flackhill, C., James, S., Soppitt, R., & Milton, K. (2017). The Coventry Grid Interview (CGI): exploring autism and
attachment difficulties. Good Autism Practice, 18(1), 62-80.
7) Fletcher-Watson, S., & Happé, F. (2019). Autism: a new introduction to psychological theory and current debate.
Abingdon: Routledge.
8) Gillberg, C. (2014). Commentary: PDA –public display of affection or pathological demand avoidance? –
reflections on O’Nions et al. (2014). Journal of Child Psychology and Psychiatry, 55: 769–770.
9) Goodman, A. (2018). Emotion Regulation and Executive Function in Children and Adolescents with Autism
Spectrum Disorder and Pathological Demand Avoidance Traits. Doctorate of Clinical Psychology, University
College London.
DAP at lower diagnostic thresholds rationale in 15 minutes. 23
THIRD JOB REFERENCES.
References.
1) Green, J., Absoud, M., Grahame, V., Malik, O., Simonoff, E., Le Couteur, A., & Baird, G. (2018). Pathological
Demand Avoidance: symptoms but not a syndrome. Lancet Child & Adolescent Health, 2(6), 455–464.
2) Happé, F., & Frith, U. (2020). Annual Research Review: looking back to look forward –changes in the concept of
autism and implications for future research. Journal of Child Psychology and Psychiatry, 61(3), 218-232.
3) Kapp, S., & Ne’eman, A. (2019). Lobbying Autism’s Diagnostic Revision in the DSM-5. In: Kapp, S. (Ed.), Autistic
Community and the Neurodiversity Movement (pp. 167-194). New York: Springer Nature.
4) Langton, E., & Frederickson, N. (2016a). Mapping the educational experiences of children with pathological
demand avoidance. Journal of Research in Special Educational Need, 16(4), 254–263.
5) Langton, E., & Frederickson, N. (2016b). Parents’ experiences of professionals’ involvement for children with
extreme demand avoidance. International Journal of Developmental Disabilities, 64(1), 16-24.
6) Lyle, C., & Leatherland, H. (2018). Preventing school exclusion: a case study of a primary aged autistic child with
ADHD and a PDA profile. Good Autism Practice, 19(2), 33-42.
7) Moore, A. (2020). Pathological demand avoidance: What and who are being pathologized and in whose interests?
Global Studies of Childhood, 10(1), 39-52.
8) Newson, E. (1989). Pathological Demand Avoidance Syndrome: diagnostic criteria and relationship to autism and
other developmental coding disorders (Research report). Retrieved from:
https://www.autismeastmidlands.org.uk/wp-content/uploads/2016/10/Pathological-Demand-Avoidance-
Syndrome.pdf (Accessed 19 June 2021).
9) Newson, E. (1996). Pathological Demand Avoidance Syndrome: a statistical update (Conference paper). Retrieved
from: https://www.autismeastmidlands.org.uk/wp-content/uploads/2016/10/Pathological-Demand-Avoidance-a-
statistical-update.pdf (Accessed 19 June 2021).
DAP at lower diagnostic thresholds rationale in 15 minutes. 24
FOURTH JOB REFERENCES.
References.
1) Newson, E., Le Maréchal, K., & David, C. (2003). Pathological demand avoidance syndrome: A necessary
distinction within the pervasive developmental disorders. Archives of Disease in Childhood, 88, 595–600.
2) O’Nions, E. (2013). Understanding thoughts and responding to emotions: exploring similarities and differences
between autism spectrum disorders, conduct problems with callous- unemotional traits, and pathological
demand avoidance. Doctor of Philosophy, King’s College London.
3) O’Nions, E., Christie, P., Gould, J., Viding, E., & Happé, F. (2014a). Development of the ‘Extreme Demand
Avoidance Questionnaire’ (EDA-Q): preliminary observations on a trait measure for Pathological Demand
Avoidance. Journal of Child Psychology and Psychiatry, 55(7), 758–768.
4) O’Nions, E., Viding, E., Greven, C., Ronald, A., & Happé, F. (2014b). Pathological demand avoidance: Exploring
the behavioural profile. Autism, 18(5), 538-544.
5) O’Nions, E., Quinlan, E., Caceres, A., Tulip, H., Viding, E., & Happé, F. (2015). Pathological Demand Avoidance
(PDA): an examination of the behavioural features using a semi-structured interview (Unpublished research).
Retrieved from:
http://pdaresource.com/files/An%20examination%20of%20the%20behavioural%20features%20associated%20with%
20PDA%20using%20a%20semi-structured%20interview%20-%20Dr%20E%20O'Nions.pdf (Accessed 19 June 2021).
6) O'Nions, E., Gould, J., Christie, P., Gillberg, C., Viding, E., & Happé, F. (2016). Identifying features of
‘pathological demand avoidance’ using the Diagnostic Interview for Social and Communication Disorders (DISCO).
European Child & Adolescent Psychiatry, 25(4), 407–419.
7) O’Nions, E., Viding, E., Floyd, C., Quinlan, E., Pidgeon, C., Gould, J., & Happé, F. (2018a). Dimensions of
difficulty in children reported to have an autism spectrum diagnosis and features of extreme/‘pathological’
demand avoidance. Child and Adolescent Mental Health, 23(3), 220–227.
DAP at lower diagnostic thresholds rationale in 15 minutes. 25
ARE WE THERE YET?
References.
1) O’Nions, E., Happé, F., Viding E., Gould, J., & Neons, I. (2018b). Demand avoidance is not necessarily defiance.
Lancet Child & Adolescent Health, 2(14), e14.
2) O’Nions, E., Happé, F., Viding, E., & Neons, I. (2021). Extreme Demand Avoidance in Children with Autism
Spectrum Disorder: Refinement of a Caregiver-Report Measure. Advances in Neurodevelopmental Disorders. DOI:
https://link.springer.com/article/10.1007/s41252-021-00203-z
3) PDA Society. (2021). What is PDA? A guide to the Pathological Demand Avoidance profile of autism (Online
booklet). Retrieved from: https://www.pdasociety.org.uk/wp-content/uploads/2021/04/What-is-PDA-booklet-
website-v2.1.pdf (Accessed 19 June 2021).
4) Reilly, C., Atkinson, P., Menlove, L., Gillberg, C., O’Nions, E., Happé, F., & Neville, B. (2014). Pathological
Demand Avoidance in a population-based cohort of children with epilepsy: Four case studies. Research in
Developmental Disabilities, 35: 3236–3244.
5) Stuart, L., Grahame, V., Honey, E., & Freeston, M. (2019). Intolerance of uncertainty and anxiety as explanatory
frameworks for extreme demand avoidance in children and adolescents. Child and Adolescent Mental Health,
25(2), 59-67.
6) Summerhill, L., & Collett, K. (2018). Developing a multi-agency assessment pathway for children and young
people thought to have a Pathological Demand Avoidance profile. Good Autism Practice, 19(2), 25–32
7) Tollerfield, I., Chapman, H., & Lovell, A. (2021). Underlying Thinking Pattern Profiles Predict Parent-Reported
Distress Responses in Autism Spectrum Disorder. Journal of Autism and Developmental Disorders. DOI:
https://link.springer.com/article/10.1007/s10803-021-05092-8
DAP at lower diagnostic thresholds rationale in 15 minutes. 26
THE LAST JOB REFERENCES.
References.
1) Truman, C., Crane, L., Howlin, P., & Pellicano, E. (2021). The educational experiences of autistic children with
and without extreme demand avoidance behaviours. International Journal of Inclusive Education. DOI:
https://doi.org/10.1080/13603116.2021.1916108
2) Trundle, G., Leam., C., Stringer, I. (2017). Differentiating between pathological demand avoidance and antisocial
personality disorder: a case study. Journal of Intellectual Disabilities and Offending Behaviour, 8(1), 13-27.
3) Woods, R. (2019a). Demand avoidance phenomena: circularity, integrity and validity –A commentary on the 2018
National Autistic Society PDA Conference. Good Autism Practice, 20(2), 28–40.
4) Woods, R. (2019b). Is the concept of Demand Avoidance Phenomena (Pathological Demand Avoidance) real or
mythical? (Conference paper). Retrieved from:
https://www.researchgate.net/publication/340279248_Is_the_concept_of_Demand_Avoidance_Phenomena_Path
ological_Demand_Avoidance_real_or_mythical (Accessed 19 June 2021).
5) Woods, R. (2020). Pathological Demand Avoidance and the DSM-5: a rebuttal to Judy Eaton’s response. Good
Autism Practice, 21(2), 74-76.
6) Woods, R. (2021). PDA Behaviour Intensity and Prevalence at different Diagnostic Thresholds (Online blog).
Retrieved from: https://rationaldemandavoidance.com/2021/04/25/pda-behaviour-intensity-and-prevalance-at-
different-thresholds/ (Accessed 19 June 2021).