1. Pathological demand avoidance (PDA)

2. PDA Newell 1983 (ADC paper 2004) A “pervasive developmental disorder”
Copyright Cardiff University
PDA
Newell 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 disorder
Happe’s 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 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 series
Evidence for heritability
Happe – 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 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 Diverting behaviours Diverting attention Delaying
blanking out; talking to themselves
Diverting attention
“you’ve got a nice face”; “what’s he doing” ; “I’ve got an idea” ; use role play in this
Delaying
“not yet”; “wait a minute”
Excuses
“I’m ill” “ I’m busy” “ I am too cold” “ it’s 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 can’t play because these cards are too old”

11. Lack 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 children’s 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 doll’s 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 people’s 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.

16. To conclude

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
Newson’s cohort of 18 show extremely concerning behaviours into adulthood
But are these cases likely to reflect extreme end of PDA spectrum ( viz. Kanner’s 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