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A guide for parents, professionals and people with Asperger's Syndrome or Autism Spectrum Disorder Level 1 and their partners.

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What is Asperger's Syndrome/ASD - Level 1? > More Info
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Professor Tony Attwood is considered
to be one of the world’s foremost experts on
Autism Spectrum Disorder.
April 29, 2024
Autism in School
May 10, 2024
Autism, ADHD & Executive Function
June 28, 2024
Understanding and Supporting Non-Speaking Autism

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Conferences & Webcasts
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Participate in Research
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Exploring Depression

Books by Tony Attwood

Tony has published many books about Asperger's Syndrome and Autism.
He has also co-authored and contributed to publications with other experts.
New Release Out Now

Autism Working:
A Seven-Stage Plan to Thriving at Work

By Tony Attwood and Michelle Garnett

Attwood & Garnett Events

Dr Michelle Garnett PhD is a clinical psychologist who has specialised in autism within her own private practice for over 27 years. She has co-authored six highly regarded books on autism, five with Prof Tony Attwood. Her 2018 book with Barb Cook is a seminal work on the female presentation, Spectrum Women: Walking to the Beat of Autism. Her most recent books Having Fun with Feelings on the Autism Spectrum and Ten Steps to Reducing Your Child’s Anxiety on the Autism Spectrum provide guidance to parents of young children on the autism spectrum.
Together Tony and Michelle have created a series of online courses that are available to download. There are also webinars consisting of a series of mater classes.

Recent Articles by Tony

Can Autism be confused with schizophrenia?
05 November 2023
Can Autism be confused with schizophrenia? The term autism was first used by the Swiss psychiatrist Eugen Bleuler in 1919 to describe a withdrawal from reality with a pathological predominance of inner...
Autism over the age of 50
05 November 2023
Autism over the age of 50 As clinicians, we have seen an increasing number of adults, and especially women, over the age of 50 seeking confirmation of autism in their developmental history and current...
Autism and Ehlers Danlos Sydrome
16 August 2023
Autism and Ehlers-Danlos Syndrome Researchers and clinicians in the autism area have known about the association between hypermobility and autism for a long time, and hypermobility is one common symptom...

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7 days ago

Tony Attwood
Welcome to "Photo Sunday"! Every Sunday, we aim to share a wildlife (theme might change) photo taken by our team members' talented autistic son. Photography has become a meaningful and therapeutic activity for him, helping him connect with nature despite facing challenges like PTSD, an intellectual disability, and agoraphobia. These images reflect his unique perspective and the beauty he finds in the wild. We hope you enjoy this week's photo as much as he enjoyed capturing it. This is also a fun activity for us both as we are self-learning and have a lot to learn yet with photography. (Sorry, this is posted on a Monday this week)#PhotoSunday #WildlifePhotography #NatureTherapy #PhotographyTherapy #CreativeOutlet #AutismAcceptance #autuallyautistic ... See MoreSee Less
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7 days ago

Tony Attwood
Examining the relationship between anxiety and pathological demand avoidance in adults: a mixed methods approach - Matt Johnson, & Helen Saunderson. (2023) Why is this research necessary? This research is crucial because it addresses the gap in understanding how Pathological Demand Avoidance (PDA) presents in adults. While PDA has been studied in children, there needs to be more knowledge about its presence and characteristics in adult populations. What did the researchers do? The researchers conducted a mixed-methods study with two experiments. Experiment 1: Utilised a correlational survey design with 170 adult participants to examine the relationship between PDA, anxiety, intolerance of uncertainty, and anticipatory responses. Experiment 2: Conducted semi-structured interviews with a subsample of 13 participants from Experiment 1 to explore their experiential perspectives on anxiety, uncertainty, and anticipation. The interviews were analysed using Interpretive Phenomenological Analysis (IPA) to identify common themes related to these experiences. What did they find? In Experiment 1, hierarchical regression analysis revealed that anxiety and intolerance of uncertainty significantly predicted PDA behaviours. Anxiety accounted for a larger portion of the variance in PDA behaviours than intolerance of uncertainty. However, anticipatory processes did not significantly add predictive power to the model. In Experiment 2, four main themes emerged from the interviews: 1. Approach-Avoidance Behavior: Participants described using approach behaviours to reduce unknowns and gain control over uncertain situations. Examples included checking their phones, using Google Maps, and performing mental assessments of situations. When approach behaviours failed, participants resorted to avoidance strategies, categorised into cognitive and physical avoidance. Cognitive avoidance involved distracting oneself from thinking about the uncertainty, while physical avoidance involved postponing or avoiding situations altogether, such as delaying appointments to prevent distress. 2. Factors Influencing Anticipatory Bias: Several factors influenced participants' anticipatory biases, including attention and vigilance, emotional regulation, and perceived cost and probability of events. Prolonged attention to uncertain events led to greater negative affect, obsessive thoughts, and a sense of reduced control. Emotional responses to anticipation varied, with some participants enjoying the excitement of positive events and others struggling with emotional regulation, especially in emotionally charged situations like holidays. The perceived importance of an event influenced the emotional and behavioural responses, with high-impact events causing more stress and requiring more mental energy to manage. 3. Vulnerability Factors Associated with Demand Avoidance: Participants frequently discussed issues related to fluctuating autonomic arousal, poor tolerance of uncertainty, a need for sameness, and difficulty predicting outcomes. Fluctuating autonomic arousal manifested as physical symptoms like shaking, sweating, and panic attacks during uncertain situations. Participants also expressed a need for predictability and familiarity, avoiding new places to reduce anxiety. Difficulty predicting outcomes often led to increased anxiety and a preference for familiar scenarios. Some participants reported feelings of self-consciousness and social judgment, which influenced their avoidance behaviours and coping strategies. 4. Experience-Based Development: All participants reported changes in their responses to anxiety, uncertainty, and anticipation as they aged. They described developing strategies to cope with these feelings, such as focusing on the present moment and using stress as motivation. The experience allowed participants to forecast a broader range of possible outcomes and adapt their perspectives, improving their ability to manage anxiety and uncertainty over time. Strategies included attentional control and living in the moment, which helped participants navigate stressful situations more effectively. What does this mean? The findings suggest that anxiety and intolerance of uncertainty are significant factors in the maintenance of PDA behaviours in adults. While anxiety emerged as a stronger predictor than intolerance of uncertainty, the relationship between these constructs indicates that both play a role in PDA. The qualitative data highlighted how adults with PDA navigate uncertainty and anxiety, emphasising the need for tailored interventions that address these specific challenges. This research provides a foundation for further exploration of PDA in adults and suggests that support strategies should focus on managing anxiety and improving tolerance of uncertainty. Where to from here? If you are new to PDA and wish to know more, we recommend attending our three-hour upcoming live webcast, PDA: An Introduction. On the same day, we will present a second three-hour course that assumes knowledge about PDA and explores a deeper understanding of the profile, strategies, and support: PDA Going Deeper. We hope you can join us. attwoodandgarnettevents.com/product/webcast-event-pda-and-autism-an-introduction-22-july-2024/attwoodandgarnettevents.com/product/webcast-event-pda-and-autism-going-deeper-monday-22-july-2024/Reference: Matt Johnson, & Helen Saunderson. (2023). Examining the relationship between anxiety and pathological demand avoidance in adults: a mixed methods approach. Frontiers in Education, 8. doi.org/10.3389/feduc.2023.1179015#actuallyautistic #autism #autistic #autismawareness #autismacceptance #autismspectrum #psychologist #psychology #alliedhealthprofessionals #teachers #psychiatry #InclusiveHealthcare #InclusiveSociety #ResearchTuesday ... See MoreSee Less
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7 days ago

Tony Attwood
Differentiating Pathological Demand Avoidance in Autism from Oppositional Defiant DisorderIn this article, we discuss the distinction between Pathological Demand Avoidance (PDA) (also known as Extreme Demand Avoidance or Persistent Drive for Autonomy) and the behavioural disorder Oppositional Defiant Disorder (ODD). PDA is characterised by an extreme avoidance of everyday demands driven by anxiety, while ODD involves patterns of defiant and aggressive behaviours. Context and ImportanceAccurate diagnosis of neurodevelopmental and behavioural conditions is critical for effective therapies and support. Misdiagnosis can lead to inappropriate interventions, exacerbating difficulties for individuals and their families. With overlapping symptoms among conditions like Pathological Demand Avoidance (PDA) and Oppositional Defiant Disorder (ODD), it is essential to delineate these conditions clearly to ensure precise diagnosis and targeted intervention.Definition of PDAPathological Demand Avoidance (PDA) is a profile within the autism spectrum characterised by an extreme avoidance of everyday demands and expectations. High anxiety levels and a need for control drive this avoidance. Individuals with PDA may exhibit social mimicry, a love of role play, sudden mood swings, impulsivity, meltdowns, and a need for novelty and engaging activities. Executive functioning is also affected, meaning that the person’s capacity for managing their attention, time, actions and belongings is less than we would expect for their chronological age. It is a bit like the brain’s air traffic control system. In PDA, this system can become overwhelmed by perceived demands, leading to an avoidance response, often starting with distraction but often escalating to either meltdown (which looks like a rage attack) or shutdown (which can range from hiding under the bedcovers to dropping to the floor in a foetal position). When calm, the person shows insight, remorse, and regret for their actions but does not see that they had a choice.Definition of ODDOppositional Defiant Disorder (ODD) is a behavioural disorder marked by a persistent pattern of angry/irritable mood, argumentative/defiant behaviour, and vindictiveness. Individuals with ODD often deliberately annoy others, blame others for their mistakes, and exhibit less anxiety-driven behaviour, such as avoidance, focusing more on oppositional actions such as arguing or deliberately annoying others. ODD behaviours are typically aimed at those in authority, and while the person may also resist demands, their resistance is generally not driven by the same high levels of anxiety seen in PDA, and they do not show the same obsessive level of resistance to demands as seen in PDA. When calm, the person continues to blame others, show defiance and not recognise their own role in the problems that occur with others.Profile ComparisonPDA Profile in Autism- Resistance to everyday demands due to anxiety-driven need for control: Individuals with PDA avoid everyday demands, including tasks that they enjoy, due to very powerful underlying anxiety that may or may not be within their awareness. The anxiety is driven by their perception that by following a request, they are losing control of their life/environment.- Social mimicry and role play: PDA individuals often engage in social mimicry and role play as a strategy to manage social interactions and demands.- Sudden mood swings and impulsivity: Mood swings and impulsive behaviours are common, driven by the individual’s anxiety and need for control.- Need for novelty and engaging activities: Individuals with PDA often enjoy and seek out novel and highly engaging activities. Oppositional Defiant Disorder (ODD)- Persistent pattern of anger, irritability, and defiant behaviour: ODD is characterised by ongoing patterns of angry and defiant behaviours directed at authority figures.- Deliberate annoyance of others and blaming others for mistakes: Individuals with ODD often intentionally annoy others and refuse to take responsibility for their actions.- Less driven by anxiety, more by oppositional behaviour: The behaviour in ODD is primarily oppositional and defiant rather than anxiety-driven as in PDA. Diagnostic ChallengesOverlap in BehavioursCertain behaviours, such as temper tantrums, irritability, defiance and aggression, are present in both PDA and ODD, complicating the diagnostic process. Both conditions are first diagnosed in childhood and, at a lower degree of severity, may occur within the family home only. A person with ODD or PDA is more likely to have ADHD. It is also possible to have both conditions.Differentiating FactorsOne key factor that helps distinguish PDA from ODD is the role of anxiety in demand avoidance. In PDA there is a pattern of avoidance that usually starts with distraction, including being charming and entertaining, e.g. giving the person who made the request a compliment, and beginning to tell them a very entertaining story. The person with PDA is often socially strategic when a demand is made to ‘buy time” to see if they can manage the request. If the request is beyond them due to their high anxiety, sense of overwhelm or lack of energy, more “oppositional behaviours” are likely to develop, such as ignoring the person, arguing with them, or going into a tantrum.Another differentiating factor is the person’s level of remorse. A person with PDA may not be able to describe their anxiety to you, but they may feel very distressed at the way they treated you during their demand avoidance. They often can say, “I don’t know why I can’t do it, but I just can’t.” The sense for them is “I can’t”, not “I won’t.” The feeling is not chosen; it is instinctive, a sense of being “wired that way.”.In ODD, demand-avoiding behaviours reflect oppositional and aggressive feelings that are often driven by a mismatch between the child’s physical and emotional needs and their environment. Personality factors such as disinhibition/lack of constraint and negative emotionality have been found to be associated with ODD.Another difference is that PDA is currently largely understood to be a part of being neurodivergent, whereas ODD occurs in typically developing children. PDA is an atypical profile of autism, so the person can usually use eye contact and other forms of nonverbal social communication and can use social skills to avoid demands. However, their understanding of neurotypical social communication is superficial, and they struggle to understand other people’s perspectives and to incorporate these into their own social behaviour without mental effort. They often have very different sensory perceptions, which commonly cause them to feel overwhelmed by the sensory world. These features of differences in social communication and sensory perception are not part of the ODD profile.If PDA is misdiagnosed as ODD:- Inappropriate use of strategies may increase anxiety and avoidance behaviours.- Failure to address underlying anxiety could lead to a deterioration in the person’s mental health and, therefore, their capacity to cope.- Autism may be missed, leading to a lack of understanding of the person, and environmental modifications that could be helpful being omitted.- Educational approaches might be too demanding, potentially leading to school refusal. If ODD is misdiagnosed as PDA:- Overly accommodating approaches might accidentally reinforce oppositional behaviours.- Underlying issues with anger management might be overlooked and, therefore, not treated.- Family dynamics could be misinterpreted, leading to coaching ineffective parenting strategies. Summary of Key Points- PDA and ODD share some surface similarities and have distinct underlying causes and manifestations.- Accurate diagnosis is crucial for implementing effective interventions and support strategies.- PDA is primarily driven by anxiety and a need for control, while ODD is characterised by defiance and aggression towards authority.- Misdiagnosis can lead to inappropriate interventions, potentially exacerbating difficulties for individuals and their families.- Ongoing research enhances our understanding of these conditions, emphasising the need for tailored approaches in clinical and educational settings.- Awareness of these distinctions is vital for professionals, caregivers, and individuals to ensure appropriate support and positive outcomes.Where to from here?We have created two consecutive half-day presentations exploring PDA in children, adolescents and adults, which are scheduled to be webcast on the 22nd July 2024. The morning session is an Introduction to PDA, with an update on research, understanding of PDA, and discussion of strategies. The afternoon session assumes knowledge from the first session and goes deeper into strategies at home, school, work and in therapy. Professionals, parents, carers, and adults with PDA will benefit.WEBCAST EVENT: PDA and Autism – An Introduction – 22 July 2024attwoodandgarnettevents.com/product/webcast-event-pda-and-autism-an-introduction-22-july-2024/WEBCAST EVENT: PDA and Autism – Going Deeper – Monday 22 July 2024attwoodandgarnettevents.com/product/webcast-event-pda-and-autism-going-deeper-monday-22-july-2024/ ReferencesO’Nions, E., & Eaton, J. (2020). Extreme/‘pathological’ demand avoidance: an overview. Paediatrics and Child Health, 30(12), 411-415.Newson, E., Le Maréchal, K., & David, C. (2003). Pathological demand avoidance syndrome: a necessary distinction within the pervasive developmental disorders. Archives of Disease in Childhood, 88(7), 595-600.Gillberg, C., Gillberg, I. C., Thompson, L., Biskupsto, R., & Billstedt, E. (2015). Extreme (“pathological”) demand avoidance in autism: a general population study in the Faroe Islands. European Child & Adolescent Psychiatry, 24(8), 979-984.Eaton, J., & Weaver, K. (2020). An exploration of the Pathological (or Extreme) Demand Avoidant profile in children referred for an autism diagnostic assessment using data from ADOS-2 assessments and from their developmental histories. Good Autism Practice.Cavanagh, M., Quinn, D., Duncan, D., Graham, T., & Balbuena, L. (2017). Oppositional Defiant Disorder Is Better Conceptualized as a Disorder of Emotional Regulation. Journal of Attention Disorders, 21(5), 381–389. doi.org/10.1177/1087054713520221#actuallyautistic #autism #autistic #autismawareness #autismacceptance #autismspectrum #psychologist #psychology #alliedhealthprofessionals #teachers #psychiatry #InclusiveHealthcare #InclusiveSociety #BlogWednesday ... See MoreSee Less
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