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Correspondence: Demand avoidance is not necessarily defiance

Jonathan Green and colleagues have usefully outlined possible mechanisms that might represent vulnerability factors promoting habitual avoidance of routine demands in autism spectrum disorder and other developmental disabilities. However, we are concerned that conceptualising pathological (or extreme) demand avoidance as a set of comorbidities, including oppositional defiant disorder, could encourage the automatic use of reinforcement based approaches to alter the child’sresponse to demands, since these strategies form the core of parenting interventions for disruptive behaviour disorders in general. Instead, we argue for much-needed research to establish what interventions are most effective for problematic demand avoidance in autism spectrum disorder.

A large body of research suggests that for disruptive children without developmental disabilities, avoidance is typically motivated by the reward of not having to engage with demands. Although reward-driven problem behaviour occurs in developmental disabilities in contexts in which parents are distracted, numerous reports suggest that avoidance of demands is often driven by an aversion to complying. In such cases, it appears that demands have become conditioned stimuli signalling threat and are experienced as sufficiently aversive to reinforce attempts to terminate them via a repertoire including distraction, diversion, and severe problem behaviour (e.g., harm to self and others).

Once high anxiety has been triggered by demands, attempting to alter behaviour via contingent reinforcement would be ineffective because it would not address the function of the behaviour: to reduce anxiety. Such approaches run the risk of escalating difficulties (see, for example, a case report by Agazzi and colleagues). Over time, inappropriate management would probably promote rapid escalation of extreme behaviour in response to demands, which might generalise to other triggers (e.g., things not being on the child’s terms). This process might contribute to the emergence of controlling behaviours in children with autism spectrum disorder and extreme demand avoidance.

We welcome Green and colleagues’ proposal that behaviours described in extreme demand avoidance be systematically assessed and included within diagnostic formulations. We would also argue against the application of terms such as oppositional defiant disorder, on the basis that the term defiant suggests that the difficulties result from the child’s willfulness. Implying that the child’s behaviour is a purposeful act primes caregivers to respond reactively. In fact, some children with autism spectrum disorder and extreme demand avoidance might simply be using all strategies at their disposal to avoid stimuli that they experience as highly aversive. Establishing evidence based interventions to help such children is a key priority.

Authors: Elizabeth O’Nions, Francesca Happé, Essi Viding, Judith Gould, Ilse Noens

Published: The Lancet Child & Adolescent Health, Volume 2, Issue 7, July 2018