Pathological Demand Avoidance (PDA): exploring the behavioural profile

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Pathological Demand Avoidance (PDA) exploring
the behavioural profile overlap with ASD
Liz ONions, PhD Student elizabeth.onions_at_kcl.ac.u
k Supervisors Prof. Francesca Happé and Dr Essi
Viding
MRC Social, Genetic and Developmental Psychiatry
Centre
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Background

• 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.
• Dont respond to intervention approaches known to
  work well in ASD

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Background

• Not included in official diagnostic manuals
  (DSM-IV/ ICD-10).
• Increasingly recognised in the UK c. 300
  clinicians/ professionals attended recent NAS
  conference.
• No research.
• Poor prognosis great parental concern,
  particularly about managing adolescents/ adults.

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Outline of the talk

• 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.

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Part 1 What is PDA?

1. Resist ordinary demands using social manipulation
2. Superficial sociability (e.g. no sense of
   responsibility, acceptable behaviour, or social
   boundaries)
3. Lability of mood impulsivity
4. Pre-occupation with role play pretend
5. Passive early history

Newson, Le Maréchal David (2003) Arch Dis Child
200388595-600
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1. Avoiding demands

• Unable to comply with even simple requests.
• 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.

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1. Uses social manipulation to avoid 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

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1. Uses social manipulation to avoid demands

• Avoidance tactics
• rages or meltdowns
• repetitive questionning
• ignoring
• 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 dont work.

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2. Superficial sociability

• Disinhibited/ socially inappropriate behaviour
  over and above demand avoidance, are not put off
  by others reactions.
• 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.

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2. Superficial sociability social
relationships

• Unable to negotiate with others their own age
  see themselves as an adult.
• Bossy and domineering towards peers. Peers
  perceive that they are infantile or are put off
  by unpredictable and dis-inhibited behaviour.
• Prefer 11 with adults, but only on their terms.
• One sided/ controlling relationship with parents,
  but do need them.

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2. Superficial sociability social persona

• 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 dont blend in it is learned behaviour.
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3. Lability of mood led by need to control

• Very extreme emotional responses to small events.
  
• Sudden switches from loving to aggression.
• Very impulsive unpredictable (e.g. prone to
  self injury/ attacking others).
• Meltdowns and panic attacks

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4. Role play

• Lives the part, not the usual pretence.
• Often used to avoid engaging socially/ as an
  adaptation to social interaction.
• Some dont seem aware of the distinction between
  reality fantasy.
• In adulthood
• 6/18 engaged in fantasy communications such as
  poison pen letters, fantasy love letters, hoax
  phone calls and letters.

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5. Passive during infancy other characteristics.

• 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.
• Other
• Obsessions centred on people or inappropriate
  topics.

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In adulthood (age 16-32 Newson et al., 2003)

• Parents concerned about aggression and violence
  (to self and others)
• Social vulnerability (many are easily led or an
  easy target)
• Their childs sense of right and wrong.

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Part 2 What do PDA look like on child behaviour
questionnaires?

• Questionnaire study new data from parents of
  children with PDA (aged 9-16yrs)
• Compared with existing data from parents of 5,000
  12yr olds, where we identified
• Conduct problems/ callous unemotional traits
  (CP/CU N28)
• Autism Spectrum Disorders (ASD N39)
• Typical levels of key behaviours in gt4,000 TD
  children

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Outcomes

• Severity of difficulties in PDA

• Nature of difficulties in PDA vs. ASD and CP/CU
• Autistic-like behaviours
• Social interaction problems
• Difficult behaviour
• Anxiety

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Autistic traits

• Score on Childhood Autism Spectrum Test for PDA
  ( ASD) top 1 of distribution

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Social interaction problems

• Similar to individuals with ASD most affected
  1

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Conduct problems/ CU traits

• Score on the Anti-Social Process Screening Device
  top 1 (like CP/CU).

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Anxiety/ emotionality

• Score on the Anxiety/ emotionality subscale of
  the SDQ in top 1 of population distribution
  (significantly higher than ASD and CP/CU).

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Twin study

• Assigned a PDA score a composite of items.
• Were identical twins more similar in PDA traits?

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Heritability

• Substantial genetic influences, plus some shared
  environmental effects.

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Future directions
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Research plans

• Experimental research into PDA to investigate...

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Development of questionnaire to measure PDA
traits...

• 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!

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Acknowledgements

• Supervisors Francesca Happe Essi Viding
• ENC Phil Christie, Dorinda Miller, Rukhsana
  Meherali, Kayleigh Storey, Carrie Munroe
• PDA website Margaret Duncan
• Clinicians Lorna Wing, Judy Gould, Francesca
  Scanlon, Rosalyn Proops, Betsy Brua, Liz Savage,
  Jacqueline Morgan.
• KCL Corina Greven, TEDS team
• Parents In particular Neville Starnes, Sam
  Parsons Paula Webb