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 ICD11
Copyright Cardiff University
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
Fundamental driver
•Demand avoidance
•Anxiety - ▫? Demand avoidance 2ndry to a need to avoid
losing control because doing so provokes unbearable anxiety
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
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)
• 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)
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
Strategies• Ignoring
▫ 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”
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
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
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
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.
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.
Diagnosis
• Not accepted in the canon
• No assessment tools
• Under-diagnosis
▫ not considered or rejected
• Over-diagnosis
▫ new fashion – see it everywhere
Education
• Need a fundamentally different approach to children with autism
• Low absolute ascertainment means a lack of experience and expertise
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)
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