Reflections on the Psychopathology of Demand Rejection and Avoidance

Honouring a long-due promise to Demand Avoidance researcher Richard Woods @Richard_Autism I will attempt to summarise a personal perspective of the psychopathology of Demand Rejection and Avoidance, conscious of the topic’s vast scientific interdisciplinarity, muddled unfortunately by rather recent research derails, causing unnecessary confusion and delays in therapeutically addressing valid psychotherapeutic necessities.

In this short article I will deliberately avoid citing/quoting any post Newson “P/E/DA” researchers, because of what I perceive as bias in their motives to establish a stand-alone diagnostic of “P/E/DA”, separate from the already existent Kanner’s and Asperger’s Autism Spectrum subcategories.

I will use instead as a lose structural frame, citations and my own personal interpretation of these citations on the topic of PDA from the National Autistic Society’s (NAS) webpage which under the “What is pathological demand avoidance?” subtitle, lists the following:

-“(PDA) is increasingly, but not universally, accepted as a behaviour profile that is seen in some individuals on the autism spectrum. (emphasis mine)

 -“This demand avoidant behaviour is rooted in an anxiety-based need to be in control.” (emphasis mine)

-“the demand avoidant profile has been found to be relatively uncommon“. (emphasis mine)

-“People with a demand avoidant profile can appear to have better social understanding and communication skills than others on the autism spectrum and are often able to use this to their advantage.” (emphasis mine)

-“uses social strategies as part of avoidance, eg distracting, giving excuses” (emphasis mine)

-“appears comfortable in role play and pretence” (emphasis mine)

-“Parents very often use the term ‘manipulative’ to describe this aspect of their child’s behaviour and will comment on how it seems to be their greatest skill” (emphasis mine)

It doesn’t require an exceedingly vast (necessary however) mental health experience to understand and notice that nearly everything mentioned in the citations above, and also much of the source material, seems to extrapolate into a rather clear anamnesis showing similarities with subcategories of Personality Disorders.

There is a generally recognised divide between the Neurodevelopmental Autistic Spectrum Conditions which have a Genetic background, and the Psychopathological Personality Disorders which seem to have a Traumatic background, each with very much different approaches to what’s best in providing support to individuals diagnosed with these conditions.

Further, the NAS material states under “Guidelines for parents” that “tried and tested strategies used with children who have other autism profiles are not effective for their child with a demand avoidant profile. This is because people with this profile need a less directive and more flexible approach than others on the autism spectrum” which seems to me fairly similar to the approach of the Dialectical Behaviour Therapy, designed to help individuals with Personality Disorders. This in my opinion seems to be also supported in the advice by the same source that the “use of structured teaching methods, which can be useful for people with other autistic profiles if individual needs have been considered, are often much less helpful for people with a demand avoidant profile and need considerable adaptation. People with this profile don’t usually respond to structure and routine. An indirect style of negotiation is more likely to lead to them feeling the control over their learning that they need.” (emphasis mine) Again, in my opinion this appears to be in direct contradiction with what the NAS seems to be emphasising that “a person with PDA does not make a deliberate choice to not comply and they can’t overcome their need to be in control”, because “feeling the control”, negotiating and responding in an expected manner to this, does to a significant extent imply the repeated use of “deliberate” choices, not to mention the sharp contrast of this behavioural profile with the clinically proven stability provided to autistic individuals by “structure and routine”.

In conclusion, I am very much concerned that exactly at a time when the future of both Kanner’s and Asperger’s Autism research have been jeopardised by historical blunders caused by arbitrary decisions made by the respective APA and the WHO to dismiss decades of research into the differences between the two major Autism subgroups in their DSM-5 and ICD-11, scientifically questionable research is being used to include -in my opinion- primarily mental health conditions into a neurodevelopmental category.

Finally, I am genuinely surprised and deeply disappointed by the @Autism NAS’s indulgent participation in this far from clarified and at the moment highly controversial subject. Their carelessness in making unclear statements such as “PDA (pathological demand avoidance) is a behaviour profile within the autism spectrum” have already given grounds to some groups such as “The Jigsaw Tree” to claim that “Pathological Demand Avoidance (PDA) is now recognised as an Autism Spectrum Condition by the National Autistic Society.” I’m curious if the NAS @Autism would confirm this conclusion…

Maybe researchers should consider another path as suggested by Rebecca McElroy whom has noticed that “PDA describes a child who is primarily led by a need to avoid demands and control situations, struggles with social communication and relationships. However, these exact same characteristics could equally be used to describe a child with disordered attachment (NICE, 2015).”

Because in my opinion, the major difference between the Autism Spectrum and the Pathologic Demand Avoidance is that while the first is Neurodevelopmental the second is Pathological.

Ref: NICE (2015). Children’s attachment: Attachment in children and young people who are adopted from care, in care or at high risk of going into care. Clinical guideline, first draft.

Disclaimer: The interpretations and re-contextualised use of the citations from the indicated NAS website are entirely my own, and therefore do not represent in any form the official position of the NAS concerning PDA.