Pathological Demand Avoidance (PDA) or Extreme Demand Avoidance
Extreme/pathological demand avoidance (PDA)
Although not recognised in the international classification systems (ICD and DSM), this controversial label has been adopted by some in the UK and mainland Europe. Confusion arises as demand avoidance itself is a common symptom. PDA has been used mainly to describe children who present with a behaviour profile characterised by the very abnormal:
- avoidance of compliance with everyday demands (using a variety of social strategies, ranging from excuses and distraction),
- anxiety when demands cannot be avoided,
- attempts to control situations,
- impulsivity as well as sudden and extreme changes of mood.
There is debate as to whether this behavioural profile is a variant of autism (and specific to it), whether it might be seen in other conditions, or whether it is a condition in its own right (Green et al., 2018).
Individuals identifying with PDA, and their families, are likely to be under unusual levels of stress. They require a detailed assessment and formulation, aiming to help manage the presenting behaviour as well as the varied underlying factors such as severe anxiety, a lack of structure, a struggle that has become entrenched, or sensory sensitivities. In the short term there might need to be a greater emphasis on reducing confrontation until a wider range of management strategies is in place.
Newson (1989), the first to report 12 cases, mentioned that PDA can be considered part of the spectrum because of the social interaction and communication impairments; the presence of repetitive behaviours, obsessive interests/behaviours, and lability of mood. However, some crucial differences were identified. The obsession to avoid everyday demands; the high level of social insight called ‘surface sociability’ and their need for control (Newson, 1996). Consequently, they may often imitate figures of authority and enact excessive imaginary play/role-play.
In 1989 Newson reported that the use of avoidance strategies depended on the child’s skills. Some common avoidance strategies include blatantly refusing; ignoring; distracting; controlling the bladder; role reversal; and acting socially inappropriate behaviours often referred to as ‘shocking behaviours’ (O’Nions, et al., 2013). Newson, Le Maréchal and David (2003) defined specific criteria such as physically incapacitating self; withdrawing into fantasy; and as a last resort extreme temper outbursts called ‘meltdowns’ (O’Nions et al., 2013). O’Nions, Christie, Gould, Viding and Happé (2014) referred to this cluster as ‘socially manipulative’ strategies. In fact, Gillberg, Gillberg, Thompson, Biskupsto and Billstedt (2015) noticed that this population acts inattentive intentionally, leading to a confusion with attention deficit hyperactivity disorder (ADHD/ADD). ASD-PDA putatively overlaps with other disorders (O’Nions et al., 2013) such as schizoid personality in childhood (Wolff & Barlow,1979) and borderline states due to anxiety, bizarre thinking under stress, and superficial interpersonal relationships (Pfefferbaum, Mullins, Rhoades & Mclaughlin, 1987).
Furthermore, Gillberg (2014) identified oppositional defiant disorder (ODD) and conduct disorder/callous-unemotional traits (CD/CU) (Viding & Jones, 2008) because of their recalcitrance and need for control. However, the use of ‘shocking behaviours’ is different. For example, the CD/CU population would enact shocking behaviours for a material gain (Frick, 2012). Whereas children with PDA would focus on avoiding demands (Viding & Jones, 2008; Gillberg, 2014). In addition, it is not uncommon to see the label of PDA in the presence of other disorders such as AD/HD and developmental coordination disorder (DCD) (Reilly et al., 2014). Newson and David (1999) also identified language delay, presumably because of children’s resistance to develop.
In fact, Newson et al. (2003), reported developmental delays or an apparent absence of milestones. The authors highlighted one child who crawled ‘only when she thought no one was looking’ (pp.598). DeSantis, Harkins, Tronick, Kaplan and Beeghly (2011) reported that emotional disorders and sensory processing disorder (SPD) are often found in neurobehavioural and neurodevelopmental disorders (Allen, Delport & Smith, 2011; Ghaziuddin & Butler, 1998; Wood, Alderman & Williams, 2008). All this contributes to the already confused parents of children with ASD-PDA and school-staff who perceive a child with multiple difficulties but no treatment seems suitable (Newson, 1989). Moreover, it has been reported that adults that support children exhibiting challenging behaviours and ASD often suffer from stress and depression (Department for Education and Skills, 2002; Benson, 2010). Noticeably, it is imperative to identify ASD-PDA as common treatments for ASD do not seem to suit those with ASD-PDA (O’Nions et al., 2013).
