Pathological demand avoidance

Pathological demand avoidance (PDA) is a profile of autism spectrum disorder and a proposed sub-type.[1] Characteristics ascribed to the condition include greater refusal to do what is asked of the person, even to activities the person would normally like, due to extreme levels of anxiety and lack of autonomy.[1] Although PDA has its own traits that are separate from autism, they generally meet the diagnostic criteria by having significant impairments in social interaction and communication and presenting restricted and repetitive behaviors. Some notable differences in PDA compared to classic autism spectrum disorders are that individuals appear to be more sociable, have far better social skills and social understanding, tend to be more interested in people than objects, are more comfortable with pretend play, and tend to be more imaginative. It is not recognized by either the DSM-5[2] or the ICD-10[3] and is unlikely to be separated out now that the umbrella diagnosis of ASD has been adopted.

In 2011, it was suggested that these symptoms could represent the condition oppositional defiant disorder (ODD).[4] Elizabeth O'Nions and others argue that unlike ASD, “children with PDA are said to use socially manipulative avoidance strategies”; and unlike ODD, they “resort to extreme, embarrassing or age-inappropriate behaviour”.[5]

The term was proposed in 1980 by the UK child psychologist Elizabeth Ann Newson.[6][7]

Recognition

Pathological demand avoidance is not recognized by the DSM-5 or ICD-10, the two main classification systems for mental disorders.[4] To be recognized, a sufficient amount of consensus and clinical history needs to be present, and as a newly proposed condition, PDA had not met the standard of evidence required at the time of recent revisions. However, DSM-5 also moved from sub-type classification to the use of ‘Autistic Spectrum Disorder’, which allows for the behavioural traits of different profiles to be described.

In 2011, the National Institute for Health and Care Excellence commented on the fact that PDA has been proposed as part of the autism spectrum but did not include further discussion within the guideline.[1] NICE guidance also expects an ‘ASD’ diagnosis be accompanied by a diagnostic assessment, providing a profile of key strengths and difficulties. Demand Avoidance is listed as a ‘sign or symptom of ASD’ (Appendix 3).[1]

Christopher Gillberg wrote a commentary article in 2014 that reviewed recent research and stated, “Experienced clinicians throughout child psychiatry, child neurology and paediatrics testify to its existence and the very major problems encountered when it comes to intervention and treatment.”[8]

Proposed diagnostic criteria

As of 2014 there are no recognized diagnostic criteria.[4] Criteria proposed by Newson include:

  1. Passive early history in the first year, avoiding ordinary demands and missing milestones
  2. Continuing to avoid demands, panic attacks if demands are escalated
  3. Surface sociability, but apparent lack of sense of social identity
  4. Lability of mood and impulsivity
  5. Comfortable in role play and pretending
  6. Language delay, seemingly the result of passivity, often caught up quickly
  7. Obsessive behavior
  8. Neurological signs (awkwardness, similar to autism spectrum disorders[9])

The underlying cause of this avoidance is said to be a high level of anxiety, usually from expectations of demands being placed on children, which can lead to a feeling of not being in control of a situation.[10] Children with PDA feel threatened when they are not in control of their environment and their actions, which triggers the fight, flight or freeze response.[11]

History

Newson first began to look at PDA as a specific syndrome in the 1980s when certain children referred to the Child Development Clinic at the University of Nottingham appeared to display and share many of the same characteristics. These children had often been referred because they seemed to show many autistic traits, but were not typical in their presentation like those with classical autism or Asperger's syndrome. They had often been labelled as 'atypical autism' or Persistent Development Disorder-Not Otherwise Specified (PDD-NOS). Both of these terms were felt by parents to be unhelpful.

When Newson was made professor of developmental psychology at the University of Nottingham in 1994, she dedicated her inaugural lecture to talking about pathological demand avoidance syndrome.[12]

In 1997, the PDA Society was established in the UK by parents of children with a PDA profile of autism. It became a registered charity in January 2016.[13]

In July 2003, Newson published in Archives of Disease in Childhood for PDA to be recognized as a separate syndrome within the pervasive developmental disorders.[6]

In 2020, an Incorporated Association was established in Australia. 'Pathological Demand Avoidance Australia Inc.' became a registered charity early 2021.[14]

Bibliography
  • Fidler, Ruth; Christie, Phil (2019). Collaborative Approaches to Learning for Pupils with PDA: Strategies for Education Professionals. Jessica Kingsley Publishers. ISBN 9781784502614.

References
  1. National Collaborating Centre for Women’s and Children’s Health (September 2011). "Autism: recognition, referral and diagnosis of children and young people on the autism spectrum": 235, 286. PMID 22624178. {{cite journal}}: Cite journal requires |journal= (help)
  2. American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
  3. "ICD-10 Version:2016". apps.who.int. Retrieved 22 January 2018.
  4. Westminster, Department of the Official Report (Hansard), House of Commons. "House of Commons Hansard Written Answers for 28 Apr 2014 (pt 0002)".
  5. Elizabeth N, Phil C, Judith G, Essi V, Francesca H (July 2014). "Development of the 'Extreme Demand Avoidance Questionnaire' (EDA-Q): preliminary observations on a trait measure for Pathological Demand Avoidance". Journal of Child Psychology and Psychiatry. 55 (7): 758–768. doi:10.1111/jcpp.12149. PMID 24117718.
  6. Newson E, Le Maréchal K, David C (July 2003). "Pathological demand avoidance syndrome: a necessary distinction within the pervasive developmental disorders". Archives of Disease in Childhood. Royal College of Paediatrics and Child Health. 88 (7): 595–600. doi:10.1136/adc.88.7.595. PMC 1763174. PMID 12818906.
  7. Feinstein, Adam (2010). A History of Autism: Conversations with the Pioneers. Wiley-Blackwell. p. 181. ISBN 978-1-4051-8654-4.
  8. Gillberg, Christopher (2014-07-01). "Commentary: PDA – public display of affection or pathological demand avoidance? – reflections on O'Nions et al. (2014)". Journal of Child Psychology and Psychiatry. 55 (7): 769–770. doi:10.1111/jcpp.12275. ISSN 1469-7610. PMID 24890260.
  9. "PDA Society • Part of the Autism Spectrum".
  10. Longo, Sharon (November 19, 2019). "Pathological Demand Avoidance and Autism". Autism Parenting Magazine. Retrieved December 13, 2020.
  11. Dundon, Raelene (21 November 2019). The Parents' Guide to Managing Anxiety in Children with Autism. Jessica Kingsley Publishers. p. 114. ISBN 9781785926570.
  12. Christie, Phil (February 20, 2014). "Elizabeth Newson obituary". The Guardian. Retrieved December 13, 2020.
  13. "About the PDA Society". PDA Society. Retrieved December 13, 2020.
  14. "PDA Australia". PDA Australia. Retrieved June 17, 2021.
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