Pathological Demand Avoidance

This section is for questions relating to therapy, assessment, formulation and other aspects of working with people in mental health services.

Pathological Demand Avoidance

Postby lizzabadger » Tue Jul 29, 2014 3:03 pm

Can I ask an ignorant question about PDA (triggered by Miriam's mentioning it in a post)?

When I was on placement in child services as a trainee (7 years ago), if the child's behaviour was generally fine at school but there was demand avoidance at home we generally recommended parenting interventions.

However I now see on parenting websites that parents seem very keen to have a "diagnosis" of PDA and to become extremely defensive if parenting/looking at their interactions with the child is mentioned.

Is it a term that is used/taken seriously in child services now?
lizzabadger
 
Posts: 133
Joined: Wed Jul 13, 2011 8:52 am

Re: Pathological Demand Avoidance

Postby miriam » Tue Jul 29, 2014 3:19 pm

Not in mine!

And it hasn't made it to the ICD or DSM or any peer reviewed journals AFAIK.
Miriam

See my blog at http://clinpsyeye.wordpress.com
User avatar
miriam
Site Admin
 
Posts: 7261
Joined: Sat Mar 24, 2007 11:20 pm
Location: Bucks

Re: Pathological Demand Avoidance

Postby midas » Tue Jul 29, 2014 4:34 pm

I recall one of the parents in our camhs service finding it and saying it perfectly described her child. We advised her to read internet based information with caution and suggested that even if it was a correct diagnosis (which we were not making) we would still advise the same strategies. A few months on and the standard parenting stuff is working.
midas
 
Posts: 187
Joined: Fri Aug 17, 2012 11:00 am

Re: Pathological Demand Avoidance

Postby lizzabadger » Tue Jul 29, 2014 7:13 pm

Thanks both. That is useful to know!
lizzabadger
 
Posts: 133
Joined: Wed Jul 13, 2011 8:52 am

Re: Pathological Demand Avoidance

Postby moosealoose » Wed Jul 30, 2014 12:26 am

This is the original paper by Elizabeth Newson in Archives of Disease in Childhood in 2003. She worked in an autism diagnostic clinic and described seeing a group of children over the years whose presentation was 'reminiscent' of autism but had several differentiating features:
http://adc.bmj.com/content/88/7/595.full

A few years ago PDA was picked up by Prof Francesca Happe, who contributed significantly to seminal autism research. I think everyone sat up a bit when she thought PDA was worth looking at more closely. Her team's work has resulted in some helpful papers.

This paper in Autism compares children identified as having PDA with children who have diagnoses of autism or conduct disorder. Using autism and CD measures and the SDQ, they show that the 'PDA' group have autistic traits at the same level as the group with autism, CD traits at the same level as the group with CD, and levels of emotional symptoms exceeding those of both children with anxiety and children with CD. This seems to support an understanding of PDA as a triple hit of autism, conduct problems, and high anxiety (which is thought to drive the demand avoidance).
http://aut.sagepub.com/content/early/20 ... 1313481861

This paper in Journal of Child Psychology & Psychiatry describes the development of a trait-measure questionnaire which distinguishes PDA features from ASD, CD and co-morbid ASD & CP. This is especially helpful as currently there are no standardized diagnostic criteria. PDA is not in DSM 5 or ICD 10 and there are significant variations amongst local knowledge and practices. For example, I work in a large county and PDA seems to be used as a diagnostic label by paediatricians in the west but not in the east!
http://onlinelibrary.wiley.com/doi/10.1 ... 9/abstract

There is a paper in press with Journal of Special Educational Needs which maps the educational needs of children with PDA, including high exclusion rates and levels of support in school. This paper in Good Autism Practice, reproduced by Autism Education Trust, describes educational strategies:
http://www.norsaca.org.uk/sites/default ... ds/5.2.pdf

As an EP I tend to work from a pragmatic stance of 'what works?'. We can do this because we are needs-led rather than diagnosis-driven. These children tend to have clear social communication difficulties (they don't 'just' look oppositional/defiant), so parents and schools tend to try strategies which work for children with typical autism spectrum conditions. Where those don't work, or are making things worse, and where the child has clear demand avoidance and sky high anxiety, to me it makes sense to try strategies which work for children with PDA.

As to the whole parenting vs developmental disorder debate, I find it interesting to reflect on the journey which autism has undergone over the last 50 or so years- from a position where it was thought to be caused by 'refridgerator mothers' to the understanding that it is one of the most heavily genetically influenced developmental disorders. Our understanding of PDA may or may not go the same way over time (it could certainly do with a less pejorative name!), but there's lots to think about along the way.
moosealoose
 
Posts: 51
Joined: Sat Jan 22, 2011 11:22 am

Re: Pathological Demand Avoidance

Postby Gilly » Wed Jul 30, 2014 9:15 am

I've worked in a a couple of child services now and its always been a diagnosis that clinicians have point blank refused to make, because either it isnt formally recognised in either diagnostic manual, or that they do not find that it is a useful way of conceptualising difficulties (in a similar way to have some people see the diagnosis of RAD).

This is perhaps because I have worked in services with clinicians who have a very strong attachment perspective when it comes to understanding and formulating difficulties, and in each of these seperate services have understood PDA broadly as attachment difficulties being seen through a biological lens, and not a distinct neurodevelopmental condition in its own right.

Having a biological explanation for your childs difficulties can be a much more manageable way of coping with the difficulties experienced, because the alternative is that its somehow more directly "your fault", which is a really difficult thing to hear, and why many parents may reach for a diagnosis.

by the by, if you look at one of the definitions of PDA from that autism paper:

an obsessive resistance to everyday demands and requests, use of socially manipulative or outrageous behaviour to avoid demands, sudden changes in mood apparently associated with a need to control, and ‘surface’ sociability, reflected in social peculiarity, difficulties with peers and lack of social constraint


could very easily be framed within an attachment perspective, and many of the children i've worked with in looked after services would meet that description without having to be diagnosed with an innate neurodevelopmental disorder.

I would be very interested in research which examined attachment and PDA, or comparison to children diagnosed with RAD/LAC children with lots of placement moves on that Extreme Demand Avoidance Questionnaire [thesis idea - anyone want it? :D], since that paper purports that the measure was able to differentiate between PDA, ASD, ASD + behavioural difficulties and conduct disorder.

[second side note: also, it just doesnt fit within the autistic spectrum!!]

the 'line' between attachment difficulties and neurodevelopmental conditions is a subject which interests me greatly, in case you hadnt noticed ;)
You're not calling for help, are you?! ;)

"The problem with quotes on the Internet is that it is hard to verify their authenticity" - Abraham Lincoln.
User avatar
Gilly
Moderator
 
Posts: 1853
Joined: Sun Sep 06, 2009 9:30 pm
Location: Doodling on Paint somewhere...

Re: Pathological Demand Avoidance

Postby cleather » Wed Jul 30, 2014 10:22 am

I found the Coventry Grid incredibly valuable when working in both CAMHS and an ASD assessment service.

http://www.aettraininghubs.org.uk/wp-co ... chment.pdf
cleather
 
Posts: 46
Joined: Thu Nov 03, 2011 5:15 pm

Re: Pathological Demand Avoidance

Postby moosealoose » Wed Jul 30, 2014 5:40 pm

Gilly wrote:the 'line' between attachment difficulties and neurodevelopmental conditions is a subject which interests me greatly, in case you hadnt noticed ;)


I share your interest, Gilly! I work in a specialist adoption support service and understanding children's needs within an attachment framework comes very naturally to me. But if we adopt a global 'attachment perspective' and blindly apply this, we potentially harm families and miss potentially helpful interventions. It's always going to be a case of formulating children's difficulties in the context of the information we have about their early lives, their parenting relationships, their temperament and a whole host of other factors. We already know that both ASD and early trauma can lead to a need to be in control, inflexibility of thought and behaviour, significant peer difficulties... Yet we differentiate these somehow, and can do the same for PDA. I have been struck by how many parents of children with PDA are teachers themselves, and how many children have siblings who are thriving.

This is an interesting paper by the specialist fostering and adoption CAMHS service at the IoP about the risks of overdiagnosing 'attachment'.
http://ccp.sagepub.com/content/early/20 ... 5.abstract

Matt Woolgar (a CP) spoke at an adoption conference recently about how we risk missing ADHD, FAS, depression, and a whole host of other 'treatable' conditions if we over focus on attachment. Yet the risk factors for our neediest children tell us to expect both- the effects of attachment difficulties and trauma, and the increased risk of developmental disorders due to possible (unidentified?) developmental difficulties in birth parents which may have contributed to their difficulties with parenting and which have a heritable component.

(Final paragraph edited following Campion's feedback)
Last edited by moosealoose on Wed Jul 30, 2014 7:12 pm, edited 1 time in total.
moosealoose
 
Posts: 51
Joined: Sat Jan 22, 2011 11:22 am

Re: Pathological Demand Avoidance

Postby Campion » Wed Jul 30, 2014 6:29 pm

moosealoose wrote:Matt Woolgar (a CP) spoke at an adoption conference recently about how we risk missing ADHD, FAS, depression, and a whole host of other 'treatable' conditions if we over focus on attachment. Yet the risk factors for our neediest children tell us to expect both- the effects of attachment difficulties and trauma, and the increased risk of developmental disorders due to likely poor genetic heritage which impacted on the parents' own ability to provide good enough care.


I'm just poking my head in to point out that I haven't seen the words 'poor genetic heritage' used one after the other like that since Eugenics was the big thing in sociology.

The only reason I mention it, is I find the 'logic' behind the Eugenic proposition dangerously fraudulent and I will pick up on the language of it extremely quickly. I will offer the benefit of the doubt though, perhaps it is a misunderstanding on my part and is not indicative of a belief that one's ability to parent effectively is directly caused by ones genetic makeup?




Campion.
'Think how many blameless lives are brightened by the blazing indiscretions of other people.' - Saki.
User avatar
Campion
 
Posts: 1181
Joined: Wed Jun 25, 2008 9:28 pm

Re: Pathological Demand Avoidance

Postby moosealoose » Wed Jul 30, 2014 7:10 pm

Thank you for pointing this out, Campion. My words were definitely clumsy. This is in part because I'm not aware of this conversation being had openly, or of research reating to this point, so I've not heard how others might phrase it.

What I meant was that birth parents who have had their children removed may well themselves have unidentified difficulties such as ADHD, FASD, BPD, ASD which have contributed to their difficulties as adults; for example with regulating their emotions or impulsive behaviour. These in turn may contribute to their difficulties with providing adequate care for their children. Most developmental and mental health difficulties have a heritable component, which in turn places their children at increased risk of developing these conditions.

Of course, this is not the same as saying that those with ADHD, FASD, ASD etc cannot adequately parent their children, which they can and do. I hope this makes more sense. I will edit my post to reflect what I actually meant.
moosealoose
 
Posts: 51
Joined: Sat Jan 22, 2011 11:22 am

Re: Pathological Demand Avoidance

Postby PsychedOut » Thu Jul 31, 2014 11:01 am

I'm finding this discussion very interesting.

In terms of Pathological Demand Avoidance; I have worked with children being assessed for autism who fit the PDA profile as described by Newson et al (2003) and to some extent validated by Franceska Happe. The debate seems to have evolved to; Is PDA best explained as an Attachment Disorder, through the Autism Spectrum or as a seperate disorder? . I think this is a shame as it forgets that autism and attachment disorders can co-exist (which is one reason I do not find the Coventry Grid useful at all).

I think that there is a lot of work that needs to be done to find out what connects neurodevelopmental disabilities (autism, PDA) and CAMHS diagnoses (oppositional defiance disorder and conduct disorder) and how attachment may influence childrens behavioural presentation and also to investigate how this relates to later adult mental health (Eating Disorders, OCD).
PsychedOut
 
Posts: 77
Joined: Fri May 24, 2013 9:56 am

Re: Pathological Demand Avoidance

Postby lingua_franca » Thu Jul 31, 2014 8:48 pm

PsychedOut wrote:I'm finding this discussion very interesting.

In terms of Pathological Demand Avoidance; I have worked with children being assessed for autism who fit the PDA profile as described by Newson et al (2003) and to some extent validated by Franceska Happe. The debate seems to have evolved to; Is PDA best explained as an Attachment Disorder, through the Autism Spectrum or as a seperate disorder? . I think this is a shame as it forgets that autism and attachment disorders can co-exist (which is one reason I do not find the Coventry Grid useful at all).


Exactly. I recently read a book on PDA and felt quite wary about what this term was being used to mean. I was a mentor for a young woman with Asperger Syndrome who fit the PDA profile to a tee, but she also came from a chaotic household and had highly anxious and overbearing parents, factors that CAMHS didn't seem to be picking up on. It was mentioned in one appointment that a sibling had died as a baby, and my ears pricked up then. I felt that a lot of the difficulties in the household probably stemmed from this bereavement. The psychiatrist didn't appear to feel that this was particularly important and I actually started to feel that the CAMHS service were colluding with the parents in their over-protectiveness, through emphasising the young woman's autism at the expense of other things. It seems to me that PDA as a label may be used as a way to pin wider interpersonal problems within the family on a particular child, one who has pervasive developmental difficulties and is therefore perhaps the natural choice for such a 'role'.
"Suppose a tree fell down, Pooh, when we were underneath it?"
"Suppose it didn't," said Pooh, after careful thought.
Piglet was comforted by this.
- A.A. Milne.
lingua_franca
 
Posts: 725
Joined: Tue Sep 14, 2010 11:29 pm

Re: Pathological Demand Avoidance

Postby miriam » Fri Aug 01, 2014 5:08 am

I think my worry is that people seem to be generalising in one direction or the other. I don't disagree for a minute that there are a cluster of kids with social communication deficits co-morbid with conduct difficulties. The difficulty is whether this is part of a neurodevelopmental syndrome that is organic in origin. My own research shows that kids with attachment difficulties and a history of maltreatment and changes in carer have just as many deficits in social communication skills as kids at the able end of the autistic spectrum. However, unless we are changing the whole model of autism to a functional one, it doesn't mean they have autism.

moosealoose wrote:I have been struck by how many parents of children with PDA are teachers themselves, and how many children have siblings who are thriving.
This is sadly a quote that could equally be written about abused kids, or those who aren't living up to parental expectations due to any number of traits or conditions. There are also epigenetic factors that impact on maltreatment, just as ASD and neurodevelopmental conditions can run in families.

To assume that "a good family" or "similar traits show in other family members" excludes non-organic conditions would be as naive as to assume that "a rough family" or "not shown in other family members" excludes the possibility of an organic condition.

the increased risk of developmental disorders due to possible (unidentified?) developmental difficulties in birth parents which may have contributed to their difficulties with parenting and which have a heritable component
I accept the principle. However, having been appointed as the expert in around 180 sets of care proceedings (and having done about 1000 neurodevelopmental assessments with a different hat on), I'd like to think I'd pick up on this in the parents, when actually I'm mainly seeing transgenerational patterns of neglect, maltreatment, traumatic adult relationships, poor life choices and the lack of mind-mindedness that focusing on survival at a more basic level engenders, rather than the same pattern as in ASD.

I worry that making things too biological is also a form of othering. We (normal people) don't commit heinous crimes, that's people with X diagnosis (personality disorder, psychopathy, callous unemotional traits). We (normal people) don't maltreat children, that's people with X diagnosis (ASD in this conversation). Actually, we need to accept that when treated badly enough almost anyone will develop mental health problems and/or treat others badly - and if the maltreatment occurs early it will lead to sub-optimal neurological, psychological and social development. We can't just attribute problems to causes within individuals. We need to address a whole load of social problems, and do more to support attachment relationships from the off, and support those who are vulnerable.

Are family nurse partnership picking up more ASD diagnoses? Are adopted children getting more ASD diagnoses than the general population? My reading of the figures is not (and in fact van Ijzendoorn's meta-analysis suggests that adoption leads to much improved developmental status, including a rise in IQ), but I'd like to see anything that indicates this is the case.
Miriam

See my blog at http://clinpsyeye.wordpress.com
User avatar
miriam
Site Admin
 
Posts: 7261
Joined: Sat Mar 24, 2007 11:20 pm
Location: Bucks

Re: Pathological Demand Avoidance

Postby lizzabadger » Fri Aug 01, 2014 9:58 am

lingua_franca wrote:
PsychedOut wrote: It seems to me that PDA as a label may be used as a way to pin wider interpersonal problems within the family on a particular child, one who has pervasive developmental difficulties and is therefore perhaps the natural choice for such a 'role'.


That would be my (completely naive - I'm not a child psych) fear.

I'm also finding this discussion very interesting - thank you to everyone who is contributing.
lizzabadger
 
Posts: 133
Joined: Wed Jul 13, 2011 8:52 am

Re: Pathological Demand Avoidance

Postby PsychedOut » Fri Aug 01, 2014 2:20 pm

I think I see things a little differently to some of what has been said here. Although agree with many of the points made!

I completely agree with Miriam's warning of generalising one way or another and agree that there is definitely a cluster of children with co-morbid social communication difficulties and conduct difficulties. I would also agree that a PDA label could be incorrectly used to gloss over interpersonal problems within a family or for children with disordered attachment. (although I don't think the quote Lizzabadger posted should be attributed to me?)

Where I find myself disagreeing somewhat is in that autism is a behaviourally defined diagnosis and therefore neither DSM-5 nor ICD-10 includes any neurological diagnostic criteria and until such technology is developed it can't be. In medical terms a child who presents with behavioural traits consistent with autism meets the criteria for ASD diagnosis regardless of whather we interpret the root of these difficulties as neurodevelopmental or attachment based. Whilst I acknowledge this is a somewhat medical interpretation, I think it is valid and meaningful to families in that autism best explains their childs difficulties at that moment and can help them access apropriate support.

I also find myself disagreeing with the general negativity towards PDA as a valid and distinctive diagnosis as part of the autism spectrum. I interpret PDA as being autism + extreme demand avoidance, high anxiety and an inherent need for control. I think that children who fit the PDA profile are distinct from children with autism, children with autism and co-morbid attachment difficulties and children with autism and conduct difficulties.

Sorry this has been a rushed post so sorry if it hasn't made much sense and that it may sound quite medicalised.
PsychedOut
 
Posts: 77
Joined: Fri May 24, 2013 9:56 am

Next

Return to Clinical Issues

Who is online

Users browsing this forum: No registered users and 6 guests