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The Continued Medicalization of Autism: 'Pathological Demand Avoidance'

So many who rail against stereotyping people with autism are the first to stereotype people with autism. Autism is not a disease, but differential developmental processing and, often, a 'crisis of instruction' Children with autism who supposedly present with ‘Pathological Demand Avoidance’ are persistently defiant; more routinely oppositional. Without going through all the specific characteristics, we already have a number of already existing diagnostic categories that identify what is, in effect, children who consistently reject attempts to engage and often refuse to respond to adults.

But instead of creating another ‘disease process,’ there are so many variables being ignored that making it all into ‘PDA’ rejects the child as an individual with his/her own personality, temperament and preferences. From environmental and functional, to adaptive, social, instructional and communicative, another constructed psychopathology follows the medical reductionist model rather than behavioral analytic and instructional which individualizes the child - not the child as a diagnosis.

One of the supposed features of ‘PDA’ identifies children for whom positive social feedback, praise and reinforcement does not always work very well. While the point that social praise is not the means to an end is accurate, this dynamic is certainly not unique. Those who spend lots of time with kids, and all kids not just those autistic, find a percentage who can quickly become more escalated and resistant when told ‘what a great job you’re doing’ (or something similar).

But the observation that reinforcing strategies can’t operate in isolation and that poorly utilized reinforcement comes with negative side effects, is a very important point with which to start. In my many decades of experience working with kids and adults with high intensity and more persistent problem (interfering) behaviors, I've often tracked down the relevance of poorly used reinforcement to include, but not limited to, edibles and electronics. Edibles should - never - be used as a reinforcer. But we’ll have to come back to that later.

Reinforcement is a part of a comprehensive instructional plan with it's effectiveness based on whether socially valid, pragmatic, and relevant skills are improving as the need for contrived reinforcement decreases. Poor reinforcement is structural; it is programmatic and environmental. It creates risk. It also can create failure which has nothing to do with the child. That adult social praise and selected items/activities don't always work is not due to 'PDA' or any other internal processes.

Consider what is known as the automaticity of reinforcement. We know that incorporating properly identified and individualized reinforcement - increasing the motivation for success - does not have to be specifically identified but will still leads to positive outcomes. That is, being nice usually works. So we can account for what works and what does not by effective assessment and observation rather than ascribing it to yet another psychopathology.

The mantra, for instance, that children with autism have anxiety because anxiety is part of autism is perfect circular reasoning. It’s also wrong. Each child is unique and individuals respond differently. Children with autism do not presumptively have anxiety disorders. Are some overly anxious? Though that might be a ‘yes,’ that doesn’t mean these children necessarily have an ‘anxiety disorder.’ But we now have still another autism 'comorbidity' in 'PDA.'

We know how to positively teach and support, to care for kids with autism no matter the degree of challenge to include supporting families/caregivers. When there is a lack of success, it is more a ‘crisis of instruction’ rather than another disease process somewhere in the child.

So many who keep railing against stereotyping people with autism seem to be the first to stereotype people with autism. Autism is not a 'disease' but a developmental processing difference and a 'crisis of instruction.' Effective, individualized and differentiated instruction is the key. Continuing to respond to autism as if it is an 'illness' is not.

Clinical Behavior Analysts need to know how to administer comprehensive ecological functional behavior assessments and build individualized and prescriptive behavior instructional plans while prioritizing the primary environment (structural) and blending universal design properties with unique - differentiated - instructional/learning methods

We need to be respectful, compassionate and individualized while integrating empirically supported and evidence-based practices in Applied Behavior Analysis and education. We need to prioritize functional communication, social competencies, learning readiness, and increased individual autonomy

We must support and provide education to families/caregivers. And we should always support the child, not differently perceived and constructed diagnoses or comorbidities.


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