Pathological demand avoidance
Pathological demand avoidance (PDA) is a proposed sub-type of autism spectrum disorder. Characteristics ascribed to the condition include greater refusal to do what is asked of the person, even to activities the person would normally like. It is not recognized by either the DSM-5 or the ICD-10 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). It was proposed in 1980 by the UK child psychologist Elizabeth Newson.
Pathological demand avoidance is not recognized by the DSM-5 or ICD-10, the two main classification systems for mental disorder. 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. 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).
In response to the recent research Prof Gillberg wrote a commentary article which 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.”
Proposed diagnostic criteria
As of 2014 there are no recognized diagnostic criteria. Proposed criteria by Newson include:
- Passive early history in the first year, avoiding ordinary demands and missing milestones
- Continuing to avoid demands, panic attacks if demands are escalated
- Surface sociability, but apparent lack of sense of social identity
- Lability of mood and impulsive
- Comfortable in role play and pretending
- Language delay, seemingly the result of passivity, often caught up quickly
- Obsessive behavior
- Neurological signs (awkwardness, similar to autism spectrum disorders)
Newson first began to look at PDA as a specific syndrome in the 1980s when certain children referred to the Child Development Clinic at Nottingham University 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 PDD-NOS. Both of these terms were felt by parents to be unhelpful. In 2003 she published in Archives of Disease in Childhood for PDA to be recognized as a separate syndrome within the pervasive developmental disorders.
- 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.
- American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
- "ICD-10 Version:2016". apps.who.int. Retrieved 22 January 2018.
- Westminster, Department of the Official Report (Hansard), House of Commons,. "House of Commons Hansard Written Answers for 28 Apr 2014 (pt 0002)".
- Newson E, Le Maréchal K, David C (July 2003). "Pathological demand avoidance syndrome: a necessary distinction within the pervasive developmental disorders". Arch. Dis. Child. 88 (7): 595–600. doi:10.1136/adc.88.7.595. PMC 1763174. PMID 12818906.
- 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.
- "PDA Society • Part of the Autism Spectrum".