Features of Pathological Demand Avoidance Identified Using the Diagnostic Interview for Social and Communication Disorders (‘DISCO')
Pathological demand avoidance (PDA) is a term coined by Elizabeth Newson to describe children within the autism spectrum who exhibited an unusual pattern of behaviour. The key characteristics of this group included (1) an obsessive resistance to complying with everyday demands; (2) an apparent ability to use behaviour strategically to subvert requests, such as distracting or using socially shocking behaviour; (3) an obsessive need for control, including domineering behaviour towards peers and adults; (5) a tendency to perceive themselves as having adult status; (6) a tendency to adopt others’ roles when interacting; and (7) obsessive behaviour, often towards targeted at particular people, who may be loved or hated (or both). Intriguingly, Newson reported an equal gender ratio, and also noted that those with PDA responded to different educational and management approaches than most individuals with autism – in particular surprise, humour and flexibility. Identifying PDA features in individuals with ASD may have an important clinical function in providing more tailored educational and support strategies.
Whilst interest in PDA is increasing apace in the UK, as yet, no validated clinician-rated instrument has been used to systematically quantify PDA features. The primary objective was to identify items that tap PDA features from within the Diagnostic Interview for Social and Communication Disorders (DISCO) (Wing & Gould, 2002). In particular, we were looking for items that are relatively low frequency across an autism spectrum sample per se, but commonly endorsed in PDA. The second objective was to examine the behavioural profile across a high scoring subset on PDA indicators in a sample assessed using the DISCO (N=153).
We identified items relevant to PDA from the DISCO on the basis of previous data on a sample reported to have been identified as having PDA (O’Nions et al., 2014), and by examining which items were endorsed as ‘marked’ in less than 30% of the sample for whom DISCO data was available (N=153). We then identified cut-offs for the purposes of these analyses, and compared our high scoring subset to the rest of the sample on other DISCO indicators.
The behavioural profile of the high scoring group resembled Newson’s descriptions. The group was characterised by high levels of lack of cooperation, use of socially manipulative behaviour, socially shocking behaviour with deliberate intent, difficulties with others, and sudden changes from loving to aggressive behaviour in particular. Anxiety was reported at very high rates in the high scoring subset. Additional features, including physical aggression, laughing at others’ distress, lack of awareness of psychological barriers, difficult or objectionable personal habits, needing constant supervision and demanding attention from caregivers were also seen more frequently in the high scoring PDA subset than the rest of the sample. All but one of the high scoring PDA group met criteria for ASD.
This study provides an important step towards deriving a clinician rated measure to tap PDA features. Differences in the behavioural profile highlight the need for further investigations of the neurocognitive and etiological basis of this profile.