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