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Pathological demand avoidance (PDA). PDA Newell 1983 (ADC paper 2004) A pervasive developmental disorder Not in DSMIV or ICD10 nor will be in DSMV or.

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Presentation on theme: "Pathological demand avoidance (PDA). PDA Newell 1983 (ADC paper 2004) A pervasive developmental disorder Not in DSMIV or ICD10 nor will be in DSMV or."— Presentation transcript:

1 Pathological demand avoidance (PDA)

2 PDA Newell 1983 (ADC paper 2004) A pervasive developmental disorder Not in DSMIV or ICD10 nor will be in DSMV or ICD11 Copyright Cardiff University


4 Diagnosis only used in UK: – so where are they in the rest of the world? (Happe & ONions) Oppositional defiant disorder; Reactive attachment disorder; Bipolar disorder in childhood; Schizoid disorder Happes study shows behavioural overlap with ASD (social interaction) Conduct problems (behaviour), but with higher levels of anxiety than either of these disorders

5 Fundamental driver Demand avoidance Anxiety - ? Demand avoidance 2 ndry to a need to avoid losing control because doing so provokes unbearable anxiety

6 Epidemiology Equal male-female ratio Prevalence ? No idea – studies based on case series Evidence for heritability Happe – twin study ` suggests that PDA traits substantially influenced by genetics

7 Salient features Based on Newsons cases 150 consecutive cases (75f, 75m) 50 children chosen randomly from these Sample of 18 followed up to adulthood ( not sure how selected – 13 f and 5 m)

8 Passive early history in first year (88%) Language delay with subsequent catch-up (90%) Resists and avoid ordinary demands (100%) strategies of avoidance are essentially socially manipulative Surface sociability, but apparent lack of sense of social identity, pride, or shame (84%) Lability of mood, impulsive (68%) Comfortable in role play and pretending (86%) Obsessive behaviour (all, but variably manifest) (Neurological involvement)

9 Demand avoidance Demands seem to lead to anxiety In avoiding them these children are: Socially manipulative Socially aware Skilled and effective Use a variety of strategies

10 Strategies Ignoring blanking out; talking to themselves Diverting attention youve got a nice face; whats he doing ; Ive got an idea ; use role play in this Delaying not yet; wait a minute Excuses Im ill Im busy I am too cold its too late Diverting behaviours mannerisms; giggling smashing things; wetting; hitting; biting; swearing Incessant talking or frenetic over-activity Flat refusal Role reversal I want you to… Rationalising I cant play because these cards are too old

11 L ack of social identity, pride, or shame Children (n=50) 84% show very inappropriate behaviour 68% show aggression to others (no sex difference) 60% have extreme outbursts or panic attacks. 82% show little sense of status or identity in others Talk to the teacher as an equal, whilst taking role of additional adult with other children 86% show no sense of pride, shame, responsibility, or identity in themselves Will insist on other childrens adherence to rules but fail to follow them themselves Lack of shame or sense of honour makes it difficult to control behaviour as another lever absent

12 Lack of sense of social identity, pride, or shame Adults (n=18) 14 adults violent when angry 5 of these were judged by their parents to be capable of badly hurting someone 7 threatened suicide, and 2 attempted it. 5 of these respondents afraid of their child, and 16 afraid for them 1 adult no sense of right or wrong, and in 7 cases parents uncertain whether the individual had a sense of right or wrong High proportion ended up in secure accommodation

13 Role play Comfortable in it Skilled and inventive Precarious sense of what is real and what is not become the role rather than role play confuse dolls with reality e.g. getting anxious if a doll is broken or reacting to a dolls facial expression Used to avoid demands

14 Obsessional behaviour The demand avoidance is obsessive in character Of the adults: 17 were described as obsessively demand avoidant 10 used other obsessions as an avoidance strategy or distraction. 12 had obsessions about specific people, 11 blame, target, or harass specific people ( also seen in children) 6 want to be with specific people (obsessionally) 4 want to be a specific person or character. 10 have contradictory obsessions, e.g. over-cleanliness/slovenliness.

15 Robustness of role play as it survives in adulthood (15/18) 5 showed six or more types of role play 10 seemed to lose touch with reality through fantasy 7 mimicked other peoples roles from video, and seven from real life 4 mimicked odd or violent behaviour 3 took mimicry to extremes so that it was hard to know who she really is 7 put on an act within their own general identity 4 acted out self generated stories or scripts, including recording an act or role on video, audiotape, or photos in an obsessive manner 6 engaged in fantasy communications such as poison pen letters, fantasy love letters, hoax phone calls and letters, false accusations to the police, and obscene stories.


17 Diagnosis Not accepted in the canon No assessment tools Under-diagnosis not considered or rejected Over-diagnosis new fashion – see it everywhere

18 Education Need a fundamentally different approach to children with autism Low absolute ascertainment means a lack of experience and expertise

19 Forensic issues Newsons cohort of 18 show extremely concerning behaviours into adulthood But are these cases likely to reflect extreme end of PDA spectrum ( viz. Kanners AD vs. broader ASD)

20 PDA and SPA What is the contribution of SPA to the population of children being diagnosed with PDA How much is adaptive demand avoidance? Think of SPA when faced with a child with this label

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