Pathological demand avoidance (PDA), or Newson's syndrome, is a proposed subtype of autism characterized by an avoidance of the ordinary demands of life. It was invented in 1980 by the UK child psychologist Elizabeth Newson.
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PDA behaviours are better explained by autism which is why it is not recognised by either the DSM-5. or ICD-10. . The UK Government does not recognise PDA, as it is not mentioned in the The Autism Strategy. However, the document does explicitly mention the daily issues that people diagnosed with Asperger's Syndrome face, along with the problems that autistic females face receiving a diagnosis . PDA is known to be a "spurious diagnosis" for autistic females
Some clinicians are increasingly prepared to diagnose children (and some adults) with PDA when this profile fits the patient most accurately. In the United Kingdom there are suggested interventions that can be followed in order to help integrate PDA children into the school system such as 'The Distinctive Clinical and Educational Needs of Children with Pathological Demand Avoidance Syndrome: Guidelines for good practice' by Phil Christie. Despite its lack of formal recognition, the National Autistic Society (a UK autism charity) have produced a leaflet entitled 'What is PDA?' in 2008.
Proposed Diagnostic criteria
The defining criteria developed 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
- Obsessive behavior
- Neurological signs (awkwardness, similar to autism spectrum disorders)
The Diagnostic Interview for Social and Communication Disorders (DISCO) was developed for use at The Centre for Social and Communication Disorders, by Lorna Wing and Judith Gould, as both a clinical and a research instrument for use with children and adults of any age. The questionnaire has 17 recognized markers for PDA within it.
Newson and her colleagues at the Elizabeth Newson Centre have been diagnosing PDA since the 1980s. This centre is part of Sutherland House Children's Services a subsidiary of Nottingham Regional Society for Children and Adults with Autism NORSACA. Phil Christie and his team of psychologists, speech therapists, teachers and play therapists complete assessments on children referred there.
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 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. She wrote up her findings in several papers based on increasingly larger groups of children. In 2003 this culminated in a proposal published in Archives of Diseases in Childhood for PDA to be recognised as a separate syndrome within the pervasive developmental disorders.
In 2007 Phil Christie had a paper published in Good Autism Practice, a peer reviewed journal published by BILD, called The Distinctive Clinical and Educational Needs of children with Pathological Demand Avoidance Syndrome GAP 8,1,2007 3-11 In 2008 the National Autistic Society, a registered charity, updated their information on PDA to include a leaflet entitled What is PDA? in keeping with their other publications "What is Asperger Syndrome?" and "What is Autism?"
Recognition
Pathological Demand Avoidance is not recognised either by the DSM-5 or ICD-10, the two main classification systems for mental disorder. The National Institute for Health and Care Excellence (which provides guidelines on best practice for UK clinicians) makes no mention of PDA in its guidelines for diagnosis of autism either in children or adults.
In April 2014 the then Minister of State for Care and Support Norman Lamb stated that the Department of Health has no plans to issue guidelines for pathological demand avoidance.
Criticisms
Although PDA is described as a subcategory of autism, some of the proposed diagnostic criteria appear to contradict the definitions of autistic spectrum disorder. For example, one criterion for PDA is "Comfortable in role play and pretending" but the DSM-5 criteria for ASD includes "difficulties in sharing imaginative play", "inflexible adherence to routines", "rigid thinking patterns".
Garralda (2003) in responding to a paper by Newsom suggests that a number of case studies described by Newsom could be explained as a child who has both a developmental disorder and a coexisting mental disorder. She also suggests that a number of the proposed features could be difficult to reliably quantify (e.g. sense of identity, pride, shame).
Suggested Interventions
Christie suggests a number of interventions that may be helpful, such as,