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Pathological Demand Avoidance (PDA): exploring the behavioural profile & overlap with ASD. Liz O’Nions, PhD Student firstname.lastname@example.org Supervisors: Prof. Francesca Happ é and Dr Essi Viding. MRC Social, Genetic and Developmental Psychiatry Centre. Background.
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Liz O’Nions, PhD Student
Supervisors: Prof. Francesca Happé and Dr Essi Viding
MRC Social, Genetic and Developmental Psychiatry Centre
PDA – proposed by Newson for children she would have otherwise termed “atypical autism”.
Inability to tolerate having anything imposed on them, social strategies to avoid demands, driven by need for control, outrageous behaviour.
Equal gender ratio.
Don’t respond to intervention approaches known to work well in ASD
Not included in official diagnostic manuals (DSM-IV/ ICD-10).
Increasingly recognised in the UK – c. 300 clinicians/ professionals attended recent NAS conference.
Poor prognosis – great parental concern, particularly about managing adolescents/ adults.
Part 1: Main features of PDA – anecdotal descriptions.
Part 2: Findings of a questionnaire study exploring the behavioural profile in PDA, compared to children with conduct problems/ callous unemotional traits and children with ASD. Heritability analysis.
Resist ordinary demands using social manipulation
“Superficial sociability” (e.g. no sense of responsibility, acceptable behaviour, or social boundaries)
Lability of mood & impulsivity
Pre-occupation with role play & pretend
Passive early history
Newson, Le Maréchal & David (2003) Arch Dis Child 2003;88:595-600
Becomes obvious when the child starts at nursery – parents get used to handling the child with “velvet gloves”.
Social nature of the demand is the problem.
1. Avoiding demands
Example of social manipulation from a commentary by D. Tantam:
“Richard, for no apparent reason, seemed to target one particular teacher at school. He made slighting remarks about her at first, and then became increasingly crude in his language until she became so distressed that she said to the head-teacher that either he went, or she did”
rages or meltdowns
changing the subject, making excuses or threats
slipping into a borrowed persona
extreme behaviour (e.g. shouting swear words, becoming violent, removing clothes, urinating on the floor, dialling 999)
praise and reproof don’t work.
1. Uses social manipulation to avoid demands
Lack of sense of acceptable limits on behaviour - Do not seem to realise that the rules apply to them. May humiliate parents in public, call the police, make false accusations etc.
2. ‘Superficial sociability’
Bossy and domineering towards peers. Peers perceive that they are infantile or are put off by unpredictable and dis-inhibited behaviour.
Prefer 1:1 with adults, but only on their terms.
One sided/ controlling relationship with parents, but do need them.
2. ‘Superficial sociability’: social relationships
May not seem socially unusual at first – gradually becomes clear that their social persona is a combination of roles.
Lack social understanding of their own but realise that they should behave in a certain way and able to copy.
Social behaviour is “unsubtle or ill-judged” – roles don’t blend in – it is “learned behaviour”.
Sudden switches from loving to aggression.
Very impulsive & unpredictable (e.g. prone to self injury/ attacking others).
Meltdowns and panic attacks
3. Lability of mood – led by need to control
“Lives the part, not the usual pretence”.
Often used to avoid engaging socially/ as an adaptation to social interaction.
Some don’t seem aware of the distinction between reality & fantasy.
6/18 engaged in fantasy communications such as poison pen letters, fantasy love letters, hoax phone calls and letters.
Passive, does not play with other children, becomes “actively passive”.
Language delay, but catch-up often rapid.
“He only crawled when he thought no-one was looking….”
Obsessions: centred on people or inappropriate topics.
Parents concerned about aggression and violence (to self and others)
Social vulnerability (many are easily led or an easy target)
Their child’s sense of right and wrong.
Compared with existing data from parents of 5,000 12yr olds, where we identified:
Conduct problems/ callous unemotional traits (CP/CU; N=28)
Autism Spectrum Disorders (ASD; N=39)
Typical levels of key behaviours in >4,000 ‘TD’ childrenPart 2: What do PDA look like on child behaviour questionnaires?
Nature of difficulties in PDA vs. ASD and CP/CU
Social interaction problems
Score on the Anxiety/ emotionality subscale of the SDQ in top 1% of population distribution (significantly higher than ASD and CP/CU).
The “Extreme Demand Avoidance” Questionnaire developed with assistance of Phil Christie.
Currently collecting data on this and the SDQ from parents of children aged 6-17.
If you are a parent of a child with ASD/ ADHD etc. or a typically developing child, please take part in the study!
ENC: Phil Christie, Dorinda Miller, RukhsanaMeherali, Kayleigh Storey, Carrie Munroe
PDA website: Margaret Duncan
Clinicians: Lorna Wing, Judy Gould, Francesca Scanlon, Rosalyn Proops, Betsy Brua, Liz Savage, Jacqueline Morgan.
KCL:CorinaGreven, TEDS team
Parents: In particular Neville Starnes, Sam Parsons & Paula Webb