2 PDA Newell 1983 (ADC paper 2004) A “pervasive developmental disorder” Copyright Cardiff UniversityPDANewell 1983 (ADC paper 2004)A “pervasive developmental disorder”Not in DSMIV or ICD10 nor will be in DSMV or ICD11
4 Diagnosis only used in UK:– so where are they in the rest of the world Diagnosis only used in UK:– so where are they in the rest of the world? (Happe & O’Nions)Oppositional defiant disorder; Reactive attachment disorder; Bipolar disorder in childhood; Schizoid disorderHappe’s study shows behavioural overlap withASD (social interaction)Conduct problems (behaviour),but with higher levels of anxiety than either of these disorders
5 Fundamental driver Demand avoidance Anxiety - ? Demand avoidance 2ndry 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 seriesEvidence for heritabilityHappe – twin study ` suggests that PDA traits substantially influenced by genetics
7 Salient features Based on Newson’s cases 150 consecutive cases (75f, 75m)50 children chosen randomly from theseSample 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 manipulativeSurface 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 manipulativeSocially awareSkilled and effectiveUse a variety of strategies
10 Strategies Ignoring Diverting behaviours Diverting attention Delaying blanking out; talking to themselvesDiverting attention“you’ve got a nice face”; “what’s he doing” ; “I’ve got an idea” ; use role play in thisDelaying“not yet”; “wait a minute”Excuses“I’m ill” “ I’m busy” “ I am too cold” “ it’s too late”Diverting behavioursmannerisms; gigglingsmashing things; wetting; hitting; biting; swearingIncessant talking or frenetic over-activityFlat refusalRole reversal“I want you to…”Rationalising“I can’t play because these cards are too old”
11 Lack of social identity, pride, or shame Children (n=50)84% show very inappropriate behaviour68% show aggression to others (no sex difference)60% have extreme outbursts or panic attacks.82% show little sense of status or identity in othersTalk to the teacher as an equal, whilst taking role of additional adult with other children86% show no sense of pride, shame, responsibility, or identity in themselvesWill insist on other children’s adherence to rules but fail to follow them themselvesLack 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 angry5 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 them1 adult “no sense of right or wrong”, and in 7 cases parents “uncertain” whether the individual had a sense of right or wrongHigh proportion ended up in secure accommodation
13 Role play Comfortable in it Skilled and inventive Precarious sense of what is real and what is notbecome the role rather than role playconfuse dolls with reality e.g. getting anxious if a doll is broken or reacting to a doll’s facial expressionUsed to avoid demands
14 Obsessional behaviour The demand avoidance is “obsessive in character”Of the adults:17 were described as obsessively demand avoidant10 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 play10 seemed to lose touch with reality through fantasy7 mimicked other people’s roles from video, and seven from real life4 mimicked odd or violent behaviour3 took mimicry to extremes so that it was “hard to know who she really is”7 put on an act within their own general identity4 acted out self generated stories or scripts, including recording an act or role on video, audiotape, or photos in an obsessive manner6 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.