Anxiety and Extreme Demand Avoidance in Children and Adolescents: the Roles of Sensory Sensitivities and Intolerance of Uncertainty

Abstract

Pathological Demand Avoidance (PDA) is a diagnosis that has been described in clinical practice but not recognised by official diagnostic and statistical manuals. The National Autistic Society (UK) describes PDA as ‘a profile of autism’; however, there is some evidence that strategies for supporting those with autism may be less effective for those identifying with the PDA profile. PDA is described as ‘driven by anxiety’; therefore, it is suggested that a better understanding of the underlying factors contributing to anxiety in this under researched group may support more effective treatment strategies, including shaping school strategies to work with autistic children. No research to date has empirically investigated the role of sensory sensitivities in PDA. Aim: This study investigates the relationship between autistic traits and extreme demand avoidance (EDA), exploring the contributing roles of both intolerance of uncertainty (IU) and sensory sensitivities (SS) to levels of anxiety; and aims to further develop an understanding of those who identify with the diagnosis of pathological demand avoidance (PDA). Method: A quantitative, between and within groups design was used. Scores from parentreport measures were analysed using descriptive and inferential statistics, including correlational analysis of the variables, mediation and structural equation modelling (SEM), and repeated measures ANOVA with paired sample t-tests of subscales. Results: Those identifying with PDA scored higher on the EDA-Q than those with Autism; however, there was no difference between ASSQ scores between those identifying with PDA and those identifying with Autism. SEM found a model with good fit of autism and EDA traits being highly corelated and predicting anxiety. IU and SS had moderating roles in the relationship between autism and EDA traits with anxiety. Discussion: PDA shows discriminant properties to autism but should be seen within the context of autism. Understanding of the impact of autistic traits in those who identify with PDA, whether they identify with autism or not, could help make sense of their diagnostic and treatment needs, and supports the concept of PDA as ‘a profile of autism’. It is suggested that there is a need to provide clarity and distinctions with the often-overlapping language used to describe different constructs within the PDA literature. Importantly, understanding sensory needs as a key underlying mechanism behind anxiety in those identifying with PDA , and moving towards a strengths based approach can support tailored, comprehensive assessment schedules and more individualised behaviour management strategies for this population.