{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,24]],"date-time":"2026-06-24T06:06:54Z","timestamp":1782281214399,"version":"3.54.5"},"reference-count":42,"publisher":"Wiley","issue":"3","license":[{"start":{"date-parts":[[2025,11,21]],"date-time":"2025-11-21T00:00:00Z","timestamp":1763683200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"},{"start":{"date-parts":[[2025,11,21]],"date-time":"2025-11-21T00:00:00Z","timestamp":1763683200000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Pediatric Investigation"],"published-print":{"date-parts":[[2026,6]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Importance<\/jats:title>\n                    <jats:p>Although pathological demand avoidance (PDA; also known as \u201cextreme\u201d or \u201cpersistent\u201d demand avoidance and persistent drive for autonomy) was first described in 1980 as a distinct behavioral profile among a subgroup of children with autism spectrum disorder, there is limited scientific evidence to support children with PDA or their parents\/guardians.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>\n                      To establish the feasibility and acceptability of the Paradigm Shift Program\n                      <jats:sup>\u00ae<\/jats:sup>\n                      , a 12\u2010week educational and training program for parents and guardians of children with PDA.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Seventy\u2010six parents\/guardians of children with PDA were enrolled in the study. Prior to the start of the program, the parents\/guardians completed a baseline assessment (demographic questions, program expectations, and several patient\u2010reported outcomes [PROs] and proxy measures). At the end of the program, parents\/guardians repeated the PROs and proxy measures, and completed a feasibility and acceptability questionnaire and anchor items.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      A total of 71 parents\/guardians completed the pre\u2010program assessment, and 60 (85%) completed the end\u2010of\u2010program assessment. Among those with both assessments, program acceptability was high, and parents\/guardians were generally satisfied with the different program elements (level of agreement &gt;70% for agreed or strongly agreed). Parents\/guardians reported significant improvement in health\u2010related quality of life (HRQOL) in 10 of the 13 PROs (all\n                      <jats:italic>P<\/jats:italic>\n                      &lt; 0.05). Parent\/guardian proxy reports also indicated significant improvements in demand characteristics (\n                      <jats:italic>P<\/jats:italic>\n                      &lt; 0.05), as well as a trend for significant improvement in conduct problems (\n                      <jats:italic>P<\/jats:italic>\n                      = 0.08), total difficulties (\n                      <jats:italic>P<\/jats:italic>\n                      = 0.05), and externalizing behavior (\n                      <jats:italic>P<\/jats:italic>\n                      = 0.05), in their child with PDA.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Interpretation<\/jats:title>\n                    <jats:p>The paradigm shift program was both feasible and acceptable. Furthermore, there was evidence that this program improved the HRQOL of parents\/guardians as well as the behavior of children with PDA.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/ped4.70028","type":"journal-article","created":{"date-parts":[[2025,11,21]],"date-time":"2025-11-21T12:48:28Z","timestamp":1763729308000},"page":"249-257","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["A comprehensive parent training program for parents of neurodivergent children with pathological demand avoidance: The Paradigm Shift Program\n                    <sup>\u00ae<\/sup>\n                    Pilot Study"],"prefix":"10.1002","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0439-9429","authenticated-orcid":false,"given":"Noelle E.","family":"Carlozzi","sequence":"first","affiliation":[{"name":"Department of Physical Medicine and Rehabilitation University of Michigan  Ann Arbor Michigan USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wendy L.","family":"Lombard","sequence":"additional","affiliation":[{"name":"Department of Physical Medicine and Rehabilitation University of Michigan  Ann Arbor Michigan USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan P.","family":"Troost","sequence":"additional","affiliation":[{"name":"Michigan Institute for Clinical and Health Research University of Michigan  Ann Arbor Michigan USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher M.","family":"Graves","sequence":"additional","affiliation":[{"name":"Department of Physical Medicine and Rehabilitation University of Michigan  Ann Arbor Michigan USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer A.","family":"Miner","sequence":"additional","affiliation":[{"name":"Department of Physical Medicine and Rehabilitation University of Michigan  Ann Arbor Michigan USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anthony T.","family":"Fauser","sequence":"additional","affiliation":[{"name":"Department of Physical Medicine and Rehabilitation University of Michigan  Ann Arbor Michigan USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Casey","family":"Ehrlich","sequence":"additional","affiliation":[{"name":"At Peace Parents  Chelsea Michigan USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2025,11,21]]},"reference":[{"key":"e_1_2_6_2_1","doi-asserted-by":"publisher","DOI":"10.1136\/adc.88.7.595"},{"key":"e_1_2_6_3_1","unstructured":"SocietyPDA.What is PDA? A guide to the pathological demand avoidance profile of autism. Accessed July 03 2025.https:\/\/www.pdasociety.org.uk\/wp\u2010content\/uploads\/2021\/04\/What\u2010is\u2010PDA\u2010booklet\u2010website\u2010v2.1.pdf"},{"key":"e_1_2_6_4_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.paed.2020.09.002"},{"key":"e_1_2_6_5_1","volume-title":"National Guideline for the assessment and diagnosis of autism in Australia","author":"Autism CRC","year":"2023"},{"key":"e_1_2_6_6_1","doi-asserted-by":"publisher","DOI":"10.1177\/13623613211034382"},{"key":"e_1_2_6_7_1","doi-asserted-by":"publisher","DOI":"10.1016\/S2352\u20104642(24)00057\u20109"},{"key":"e_1_2_6_8_1","doi-asserted-by":"publisher","DOI":"10.3389\/feduc.2024.1230011"},{"key":"e_1_2_6_9_1","doi-asserted-by":"publisher","DOI":"10.1176\/appi.books.9780890425787"},{"key":"e_1_2_6_10_1","unstructured":"WHO.International Classification of Functioning Disability and Health (ICF).2010. Accessed July 03 2025.http:\/\/www.who.int\/classifications\/icf\/en\/"},{"key":"e_1_2_6_11_1","unstructured":"PDA North America. Accessed July 03 2025.http:\/\/www.pdanorthamerica.org"},{"key":"e_1_2_6_12_1","doi-asserted-by":"publisher","DOI":"10.1016\/S2352\u20104642(18)30044\u20100"},{"key":"e_1_2_6_13_1","unstructured":"MiltonD.Pathological Demand Avoidance (PDA) and alternative explanations: a critical overview. In: The Participatory Autism Research Collective;2018."},{"key":"e_1_2_6_14_1","doi-asserted-by":"publisher","DOI":"10.1177\/2043610619890070"},{"key":"e_1_2_6_15_1","unstructured":"Reframing Autism.Pathological demand avoidance (PDA) and autism: a guide for allies.2025. Accessed July 03 2025. \u00a0https:\/\/reframingautism.org.au\/pathological\u2010demand\u2010avoidance\u2010pda\u2010and\u2010autism\u2010guide\u2010for\u2010allies\/"},{"key":"e_1_2_6_16_1","unstructured":"National Autistic Society.Demand avoidance.2025. Accessed July 03 2025.https:\/\/www.autism.org.uk\/advice\u2010and\u2010guidance\/topics\/behaviour\/demand\u2010avoidance"},{"key":"e_1_2_6_17_1","doi-asserted-by":"publisher","DOI":"10.1002\/jcv2.12270"},{"key":"e_1_2_6_18_1","unstructured":"PDA Society.PDA in our words.2024. Accessed July 03 2025.https:\/\/www.pdasociety.org.uk\/research\u2010professional\u2010practice\/in\u2010our\u2010words\/"},{"key":"e_1_2_6_19_1","unstructured":"EhrlichC.The PDA lens: A new vision for supporting nervous system disability. Psychotherapy Networker.2025. 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