PDA – is there another explanation?
Only a short while ago, PDA (pathological demand avoidance) was a term little known to the public; however, due to an increased presence in social media, PDA is becoming a household term. It is not surprising, therefore, that services are under increasing pressure to consider PDA as a diagnosis. Whilst PDA currently falls under the umbrella diagnosis of autism spectrum disorders (ASD) (DSM-5), individual services/clinicians can choose to use PDA as a descriptive diagnosis alongside a clinical diagnosis of ASD. It was for this reason that I was asked to review the existing research literature on PDA to help the service decide whether to use PDA as a descriptive diagnosis, a regular request from families in the wake of a TV series on childhood behavioural difficulties aired earlier this year.
Professor Elizabeth Newson (founder of the term PDA) and her colleagues suggest that PDA accurately describes a group of children who, similarly to children on the autistic spectrum, present with difficulties in social communication, relationships and use of language, as well as displaying rigidity and obsessive behaviour. However, they highlight a few key, but important differences between PDA and ASD. Autistic children display rigidity through rules, routine and predictability; in PDA their rigidity is in their need to avoid demands and control situations, which can often lead to the child appearing extremely impulsive in their emotions and behaviour, as they react to demands as they perceive them. Whilst autistic children often show little or no impression of sociability, children with PDA display surface sociability; however, they often fail to recognise boundaries and struggle to comprehend the contextual factors and social norms of relationships. Autistic children invariably have marked difficulties in social communication with disordered pragmatics, eye contact and facial expression; on the contrary, whilst children with PDA often experience early language delay there is often a good degree of catch up; their language is not as disordered and their expressions and eye contact can be fair; however, speech content can seem odd or bizarre and, importantly, communication can be significantly effected by demand avoidance. The predominant characteristic of children with PDA is their continued resistance and avoidance of the ordinary demands of life. Whilst autistic children can be reluctant to comply, this is often in a non-social way; they lack the empathy to make excuses or develop strategies for avoidance. In contrast, children with PDA develop multiple strategies of avoidance, which they are able to adapt to the adult involved and can appear socially manipulative. (Newson, 2000).
As I began to review the small, but growing, research literature on PDA I was struck by the similarities between the proposed characteristics of PDA and those shown by children with attachment difficulties. PDA describes a child who is primarily led by a need to avoid demands and control situations, struggles with social communication and relationships. However, these exact same characteristics could equally be used to describe a child with disordered attachment (NICE, 2015). Furthermore, research has shown that children with a diagnosed attachment disorder may be as impaired as autistic children in their social relatedness and language skills (Sadiq, et al., 2012), and one study found that the symptoms of ASD and attachment disorder can be comorbid (Giltaij, et al., 2015). Therefore, given that PDA is currently considered a form of ASD, it is fair to assume that a similar overlap in symptoms may exist between PDA and attachment disorders.
Whilst PDA certainly does describe a group of children who do not fit the traditional ASD diagnosis, I believe there is a need for further research into the overlap between the symptoms of PDA and attachment disorders, to ensure that PDA, as a descriptive diagnosis, is used effectively and accurately. In the meantime, clinicians under pressure to diagnose PDA may be wise to exercise caution; look at all of the facts, keep an open mind and ask yourself: ‘Is there another explanation?’
Newcastle upon Tyne
Giltaij, H.P., Sterkenburg, P.S. & Schuengel, C. (2015). Psychiatric diagnostic screening of social maladaptive behaviour in children with mild intellectual disability: differentiating disordered attachment and pervasive developmental disorder. Journal of Intellectual Disability Research, 59(2), 138–149.
Newson, E. (2000). Defining criteria for diagnosis of pathological demand avoidance syndrome (2nd revision). Nottingham: The Elizabeth Newson Centre.
NICE (2015). Children’s attachment: Attachment in children and young people who are adopted from care, in care or at high risk of going into care. Clinical guideline, first draft.
Sadiq, F.A., Slator, L., Skuse, D. et al. (2012). Social use of language in children with reactive attachment disorder and autism spectrum disorders. European Child and Adolescent Psychiatry, 21, 267–276.
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