Dimensions of difficulty


Dimensions of difficulty in children reported to have an autism spectrum diagnosis and features of extreme pathological demand avoidance


A subset of individuals with autism spectrum disorder (ASD) resemble descriptions of extreme/‘pathological’ demand avoidance, displaying obsessive avoidance of everyday demands and requests, strategic or ‘socially manipulative’ behaviour and sudden changes in mood. Investigating challenging presentations using dimensional description may prove preferable to identifying subgroups. However, there remains an imperative to explore which behavioural traits appear most problematic to inform quantitative investigation.

This study provides an in-depth exploration of parent perspectives on maladaptive behaviour in children reported to have an autism spectrum diagnosis and features of extreme/‘pathological’ demand avoidance.

Key Practitioner Message

  • Children with ASD who resemble descriptions of extreme/‘pathological’ demand avoidance obsessively avoid complying with everyday demands, engage in apparently ‘manipulative’ behaviour and exhibit sudden changes in mood. We collected interview data from parents of children with ASD (parent-reported) and these features about their child’s maladaptive behaviour.
  • Subtle differences emerged compared to previous accounts of this profile. These included additional problems relating to the child’s frequent attempts to control situations and others’ activities (e.g. by insisting that others abide by their rules or meet their demands). In our sample, avoidance behaviours could be described as ‘strategic’ rather than ‘manipulative’. Parents perceived that a range of factors played a role in triggering extreme behaviour, including a negative emotional response to perceived pressure (in line with previous accounts), as well as sensory sensitivities, phobias and anxiety about the unknown.
  • These findings add to the literature on extreme noncompliance, mood variability and attempts to control situations and others’ activities in ASD, and they motivate examination of similarities and differences in the manifestation and drivers of these behaviours compared with other non-ASD profiles. Our data highlight the importance of these dimensions as intervention targets, given their considerable impact on daily life.


Authors: Elizabeth O’Nions, Essi Viding, Caroline Floyd, Emma Quinlan, Connie Pidgeon, Judith Gould & Francesca Happé

Published: Journal of Child and Adolescent Mental Health (CAHM), 2018

Winner of CAMH Best Paper Award 2019.