PATHOLOGICAL DEMAND AVOIDANCE. Saturday 9 th November 2013 Surrey NAS Conference Kate Webb Deputy Headteacher Freemantles School

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1 PATHOLOGICAL DEMAND AVOIDANCE Saturday 9 th November 2013 Surrey NAS Conference Kate Webb Deputy Headteacher Freemantles School

2 AGENDA What is it? What does it look like? Educational impact in the classroom Conclusion Questions

3 PATHOLOGICAL DEMAND AVOIDANCE Term was developed by Elizabeth Newson in the early 1980 s Had been seeing children in her clinic that presented differently to those with ASD First peer review article was published in 2003 in the Archives of Diseases in Childhood NAS published information in 2008

4 PERVASIVE DEVELOPMENTAL DISORDER Like Autism is has been classified as a PDD PERVASIVE suggests the effects can be seen in all of a child's development DEVELOPMENTAL present at birth gradually becoming ore apparent throughout development DISORDER more than a straightforward delay

5 PATHOLOGICAL DEMAND AVOIDANCE Is known as a PDD NOS (not other wise specified) Further research being done by Dr Paul Christie Consultant Clinical Psychologist at the Elizabeth Newson centre.

6 WHY DO WE NEED TO BE AWARE OF IT? Now it is a PDD-NOS these are under the Autism umbrella Autism criteria will incorporate several diagnoses from DSM-IV including autistic disorder, Asperger s disorder, childhood disintegrative disorder and pervasive developmental disorder (not otherwise specified) into the diagnosis of autism spectrum disorder for DSM-5 to help more accurately and consistently diagnose children with autism,

7 DEFINING CRITERIA Passive early history Resists and avoids ORDINARY demands of life! Surface sociability Liability of mood Comfortable in role play and pretending Obsessive behaviour Neurological involvement Language delay

8 PASSIVE EARLY HISTORY Doesn t reach drops toys Just watches Delayed milestones As more is expected of them they become more actively passive (strongly objecting to normal demands) Professionals often see the child as puzzling but normal

9 RESISTS AND AVOIDS ORDINARY DEMANDS OF LIFE Avoidance can be the greatest social and cognitive skill Strategies used are socially manipulative - Distraction - Procrastination - Negotiation - Physically incapacitating self - Withdrawing to fantasy - Physical outbursts/attacks

10 SURFACE SOCIABILITY At first sight normally sociable but ambiguous Wants others to admire shocks others with lack of boundaries No sense of responsibility Uninhibited behaviour

11 LIABILITY OF MOOD Switches from cuddling to thumping for no obvious reason Very impulsive Switching of mood may be as a response to perceived pressure Emotions may seem like an act May apologise but reoffend immediately

12 FANTASY, ROLE PLAY AND PRETENDING Lose touch with reality May take over second hand roles as a convenient way of being (coping strategy) May behave to other children like the teacher, can mimic and extend style to suit mood Enjoys dolls/toys animals/domestic play Can cope with conversations involving shared pretending.

13 LANGUAGE DELAY Good degree of catch up often sudden Good eye contact Social timing fair except when interrupted! Normal facial expression Social mimicry more common than video mimicry.

14 OBSESSIVE BEHAVIOUR All behaviour described carried out in an obsessive way Low level achievement in school because of motivation to avoid demands is so sustained Social obsessions (other children or adults)

15 NEUROLOGICAL INVOLVEMENT Clumsiness and physical awkwardness Crawling late Absences, fits But not enough hard evidence YET!!

16 OPPOSITIONAL DEFIANT DISORDER These children are often wilful Very aware of their actions Show little emotional connection Being grouped with conduct disorder/problems and callous unemotional traits. PDA is anxiety driven

17 RESEARCH In terms of research it is very NEW! Less than 10 years worth of evidence. It is not yet recognised in the DSM-5 - Therefore some clinicians refuse to diagnose (postcode lottery) - A child s autism presentation can change over time

18 EDUCATIONAL IMPACT IN THE CLASSROOM Where do these children appear to fit? - Need very flexible environment - ASD provision doesn t always offer this we can be too rigid!! - Often need individual packages and some cant cope with school provision at all.

19 AS A LEARNER IN THE CLASSROOM Anxiety driven need to be in control Explosive behaviour when things go wrong May articulate violence Can slip under the radar Poor self esteem Expressed desire to have friends but sabotages and is vulnerable to social naivety.

20 AS A LEARNER (CON) Expressed desire to be on par or better than others Ambivalence about succeeding and enjoying an activity Very poor emotional regulation Variability in behaviour Emotional well being

21 COLLABORATIVE PROBLEM SOLVING Plan A seeing through the imposition of the adults will Plan C Dropping the expectation completely Plan B engaging the child in such a way that the problem is resolved in a mutually satisfactory manner.

22 WHAT DO THEY NEED? Highly individualised approach less directive Calm staff Reduced confrontation Disguised expectations Reduced rules Imaginative ideas can be more flowery than usual ASD strategies Drama/role play Complex language Building personal understanding and self esteem

23 STAMINA! Requires constant flexible problem solving Hard to warm to someone who struggles to conform Tiring being with someone who is unpredictable Hard to be around someone who makes no accommodation for you or your frame of mind/situation

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25 What s PDA? Well the clue is in the name. It means if someone asks me to do something, I am likely to say no.that s me all over isn t it?! But I m also like a cat. It depends on how you ask me. If you ask me the right way, its like stroking a cat s fur the way it grows. I may even purr! But if you ask me the wrong way, its like stroking a cats fur backwards. I m likely to hiss!

26 TOLERANCE V DEMAND Key to success is keeping these synchronised Tolerance Demand Tolerance

27 FUTURE DISCO(diagnostic interview for social and communication disorders) Lorna Wing Centre has identified 17 questions that relate to PDA to help clinicians. Hampshire have produced draft guidelines for schools on PDA Will be seeing more children with this presentation?

28 CONCLUSION AET good practice report 2011 I suppose my message to schools is, you re there for the children, they re not there for you. And therefore, actually you do what you can to adapt to the children you ve got, and not expect the children to become the children you want them to be.

29 REFERENCES NAS Pathological Demand Avoidance conference documentation from Edinburgh PDA and ASD mind map created by George Timlin, Warwickshire County Council, 2009

30 QUESTIONS How do you recognise PDA vs autism, ADHD, other behavioural issues? How best to support a child wth PDA at home and in the school setting. What medications might help (if any)? How to motivate to participate in lessons they do not enjoy or see the point of. Is PDA often overlooked or confused with other conditions like bipolar disorder? How to deal with issues of learning/homework; how to assist child at home as he has lots of demand avoidance.

31 Kate Webb - kwebb@freemantles.surrey.sch.uk Freemantles Outreach - Vanessa Oldham Leader of Outreach - voldham@freemantles.surrey.sch.uk