Newson 2003: Table 1

Pathological Demand Avoidance Syndrome: A Necessary
Distinction Within the Pervasive Developmental Disorders
E. Newson, K. Le Marechal, C. David
Archives of Disease in Childhood, 2003

Table 1: Defining criteria for diagnosis of pathological demand avoidance syndrome (with descriptive notes and comparison with autism)

PDA children Autistic/Asperger’s children

(1) Passive early history in first year: Often doesn’t reach, drops toys, “just watches”; often delayed milestones. As more is expected, child becomes “actively passive”, i.e. strongly objects to normal demands, resists. A few actively resist from the start, everything is on own terms. Parents tend to adapt so completely that they are unprepared for the extent of failure once child is subjected to ordinary group demands of nursery or school; they realise child needs “velvet gloves” but don’t perceive this as abnormal. Professionals too see child as puzzling but normal at first. Seems more abnormal much earlier; lack of social response and lack of empathy alert parents, together with poor body language and stereotypic behaviour

(2) Continues to resist and avoid ordinary demands of life: Seems to feel under intolerable pressure from normal expectations; devotes self to actively avoiding these. Demand avoidance may seem the greatest social and cognitive skill, and most obsessional preoccupation. As language develops, strategies of avoidance are essentially socially manipulative, often adapted to adult involved; they may include:

*Distracting adult: “Look out of the window!”, “I’ve got you a flower!”, “I love your necklace!”, “I’m going to be sick”, “Bollocks!—I said bollocks!”

Acknowledging demand but excusing self: “I’m sorry, but I can’t”, “I’m afraid I’ve got to do this first”, “I’d rather do this”, “I don’t have to, you can’t make me”, “you do it, and I’ll ...”, “Mummy wouldn’t like me to”.

Physically incapacitating self: hides under table, curls up in corner, goes limp, dissolves in tears, drops everything, seems unable to look in direction of task (though retains eye contact), removes clothes or glasses, “I’m too hot”, “I’m too tired”, “It’s too late now”, “I’m handicapped”, “I’m going blind/deaf/spastic”, “My hands have gone flat”.

Withdrawing into fantasy, doll play, animal play: talks only to doll or to inanimate objects; appeals to doll, “My girls won’t let me do that”, “My teddy doesn’t like this game”; “But I’m a tractor, tractors don’t have hands”; growls, bites.

Reducing meaningful conversation: bombards adult with speech (or other noises, e.g. humming) to drown out demands; mimics purposefully; refuses to speak.

(As last resort): outbursts, screaming, hitting, kicking; best construed as panic attack.
Can be reluctant, but ignores or shuts out pressure in a non-social way, without acknowledging others’ needs. Has very few conscious strategies for avoidance. Doesn’t adapt particular strategy for particular person. Doesn’t have enough empathy to make excuses, and usually not enough empathic language either. Direct, not devious.

(3) Surface sociability, but apparent lack of sense of social identity, pride, or shame: At first sight normally sociable with enough empathy to manipulate adults as shown above; but ambiguous and without depth. No negotiation with other children, doesn’t identify with children as a category: the question “Does she know she’s a child?” makes sense to parents, who recognise this as a major problem. Wants other children to admire, but usually shocks them by complete lack of boundaries. No sense of responsibility, not concerned with what is “fitting to her age” (might pick fight with toddler). Despite social awareness, behaviour is uninhibited, e.g. unprovoked aggression, extreme giggling/inappropriate laughter, or kicking/screaming in shop or classroom. Prefers adults but doesn’t recognise their status. Seems very naughty, but parents say “not naughty but confused” and “it’s not that she can’t or won’t, but she can’t help won’t” — parents at a loss, as are others. Praise, reward, reproof, and punishment ineffective; behavioural approaches fail. Because of lack of social empathy, autistic children (even Asperger’s children) don’t purposefully manipulate, though people around them may feel manipulated by the situation or by fate. They give no impression of sociability, except with questions or statements about their preoccupying interests from verbal children. They may become more sociable in time, but seldom develop real (natural) social empathy.

(4) Lability of mood, impulsive, led by need to control: Switches from cuddling to thumping for no obvious reason; or both at once (“I hate you” while hugging, nipping while handholding). Very impetuous, has to follow impulse. Switching of mood may be response to perceived pressure; goes “over the top” in protest or in fear reaction, or even in affection; emotions may seem like an “act”. Activity must be on child’s terms; can change mind in an instant if suspects someone else is exerting control. May apologise but reoffend at once, or totally deny the obvious. Teachers need great variety of strategies, not rule based: novelty helps. Autistic children are seldom impulsive; they work to (their own) rules, and parents learn what will upset them. They do not put on an act for someone else until very much older, if then. Rules, routine and predictability help.

(5) Comfortable in role play and pretending: Some appear to lose touch with reality. May take over second-hand roles as a convenient “way of being”, i.e. coping strategy. Many behave to other children like the teacher (thus seem bossy); may mimic and extend styles to suit mood, or to control events or people. Parents often confused about “who he really is”. May take charge of assessment in role of psychologist, or using puppets, which helps cooperation; may adopt style of baby, or of video character. Role play of “good person” may help in school, but may divert attention from underachievement. Enjoys dolls/toy animals/domestic play. Copes with normal conventions of shared pretending. Indirect instruction helps. Inflexibility, lack of symbolic and imaginative play and lack of empathy all make it very difficult for autistic children to pretend (other than by arranging miniature objects), or to take roles more fully than by simple echoing—though Asperger’s children may learn “scripted” roles, with difficulty and without fluency. Indirectness confuses.

(6) Language delay, seems result of passivity: Good degree of catch-up, often sudden. Pragmatics not deeply disordered, good eye contact (sometimes over strong); social timing fair except when interrupted by avoidance; facial expression usually normal or over vivacious. However, speech content usually odd or bizarre, even discounting demand-avoidant speech. Social mimicry more common than video mimicry; brief echoing in some. Repetitive questions used for distraction, but may signal panic. Language is both delayed and deviant, non-existent in many. Even Asperger’s children show very disordered pragmatics of language, poor eye contact and social timing, little facial expression or gesture.

(7) Obsessive behaviour: Much or most of the behaviour described is carried out in an obsessive way, especially demand avoidance: as a result, most children show very low level achievement in school because motivation to avoid demands is so sustained, and because the child knows no boundaries to avoidance. Other obsessions tend to be social, i.e. to do with people and their characteristics; some obsessionally blame or harass people they don’t like, or are overpowering in their liking for certain people; children may target other individual children. Autistic children are also obsessive, but less so with social topics. They are not obsessively focused on demand avoidance, and do not use obsessions for manipulative purposes. Order, arrangements and perceptual fascinations.

(8) Neurological involvement: Soft neurological signs are seen in the form of clumsiness and physical awkwardness; crawling late or absent in more than half. Some have absences, fits, episodic dyscontrol, or generalised excitability. Not enough hard evidence as yet. Some comparable involvement in autism; less in terms of crawling and episodic dyscontrol.

Table 1: Defining criteria for diagnosis of pathological demand avoidance syndrome (with descriptive notes and comparison with autism)
PDA children	Autistic/Asperger’s children
(1) Passive early history in first year: Often doesn’t reach, drops toys, “just watches”; often delayed milestones. As more is expected, child becomes “actively passive”, i.e. strongly objects to normal demands, resists. A few actively resist from the start, everything is on own terms. Parents tend to adapt so completely that they are unprepared for the extent of failure once child is subjected to ordinary group demands of nursery or school; they realise child needs “velvet gloves” but don’t perceive this as abnormal. Professionals too see child as puzzling but normal at first.	Seems more abnormal much earlier; lack of social response and lack of empathy alert parents, together with poor body language and stereotypic behaviour
(2) Continues to resist and avoid ordinary demands of life: Seems to feel under intolerable pressure from normal expectations; devotes self to actively avoiding these. Demand avoidance may seem the greatest social and cognitive skill, and most obsessional preoccupation. As language develops, strategies of avoidance are essentially socially manipulative, often adapted to adult involved; they may include: Distracting adult: “Look out of the window!”, “I’ve got you a flower!”, “I love your necklace!”, “I’m going to be sick”, “Bollocks!—I said bollocks!” Acknowledging demand but excusing self:* “I’m sorry, but I can’t”, “I’m afraid I’ve got to do this first”, “I’d rather do this”, “I don’t have to, you can’t make me”, “you do it, and I’ll ...”, “Mummy wouldn’t like me to”. Physically incapacitating self: hides under table, curls up in corner, goes limp, dissolves in tears, drops everything, seems unable to look in direction of task (though retains eye contact), removes clothes or glasses, “I’m too hot”, “I’m too tired”, “It’s too late now”, “I’m handicapped”, “I’m going blind/deaf/spastic”, “My hands have gone flat”. Withdrawing into fantasy, doll play, animal play: talks only to doll or to inanimate objects; appeals to doll, “My girls won’t let me do that”, “My teddy doesn’t like this game”; “But I’m a tractor, tractors don’t have hands”; growls, bites. Reducing meaningful conversation: bombards adult with speech (or other noises, e.g. humming) to drown out demands; mimics purposefully; refuses to speak. (As last resort): outbursts, screaming, hitting, kicking; best construed as panic attack.	Can be reluctant, but ignores or shuts out pressure in a non-social way, without acknowledging others’ needs. Has very few conscious strategies for avoidance. Doesn’t adapt particular strategy for particular person. Doesn’t have enough empathy to make excuses, and usually not enough empathic language either. Direct, not devious.
(3) Surface sociability, but apparent lack of sense of social identity, pride, or shame: At first sight normally sociable with enough empathy to manipulate adults as shown above; but ambiguous and without depth. No negotiation with other children, doesn’t identify with children as a category: the question “Does she know she’s a child?” makes sense to parents, who recognise this as a major problem. Wants other children to admire, but usually shocks them by complete lack of boundaries. No sense of responsibility, not concerned with what is “fitting to her age” (might pick fight with toddler). Despite social awareness, behaviour is uninhibited, e.g. unprovoked aggression, extreme giggling/inappropriate laughter, or kicking/screaming in shop or classroom. Prefers adults but doesn’t recognise their status. Seems very naughty, but parents say “not naughty but confused” and “it’s not that she can’t or won’t, but she can’t help won’t” — parents at a loss, as are others. Praise, reward, reproof, and punishment ineffective; behavioural approaches fail.	Because of lack of social empathy, autistic children (even Asperger’s children) don’t purposefully manipulate, though people around them may feel manipulated by the situation or by fate. They give no impression of sociability, except with questions or statements about their preoccupying interests from verbal children. They may become more sociable in time, but seldom develop real (natural) social empathy.
(4) Lability of mood, impulsive, led by need to control: Switches from cuddling to thumping for no obvious reason; or both at once (“I hate you” while hugging, nipping while handholding). Very impetuous, has to follow impulse. Switching of mood may be response to perceived pressure; goes “over the top” in protest or in fear reaction, or even in affection; emotions may seem like an “act”. Activity must be on child’s terms; can change mind in an instant if suspects someone else is exerting control. May apologise but reoffend at once, or totally deny the obvious. Teachers need great variety of strategies, not rule based: novelty helps.	Autistic children are seldom impulsive; they work to (their own) rules, and parents learn what will upset them. They do not put on an act for someone else until very much older, if then. Rules, routine and predictability help.
(5) Comfortable in role play and pretending: Some appear to lose touch with reality. May take over second-hand roles as a convenient “way of being”, i.e. coping strategy. Many behave to other children like the teacher (thus seem bossy); may mimic and extend styles to suit mood, or to control events or people. Parents often confused about “who he really is”. May take charge of assessment in role of psychologist, or using puppets, which helps cooperation; may adopt style of baby, or of video character. Role play of “good person” may help in school, but may divert attention from underachievement. Enjoys dolls/toy animals/domestic play. Copes with normal conventions of shared pretending. Indirect instruction helps.	Inflexibility, lack of symbolic and imaginative play and lack of empathy all make it very difficult for autistic children to pretend (other than by arranging miniature objects), or to take roles more fully than by simple echoing—though Asperger’s children may learn “scripted” roles, with difficulty and without fluency. Indirectness confuses.
(6) Language delay, seems result of passivity: Good degree of catch-up, often sudden. Pragmatics not deeply disordered, good eye contact (sometimes over strong); social timing fair except when interrupted by avoidance; facial expression usually normal or over vivacious. However, speech content usually odd or bizarre, even discounting demand-avoidant speech. Social mimicry more common than video mimicry; brief echoing in some. Repetitive questions used for distraction, but may signal panic.	Language is both delayed and deviant, non-existent in many. Even Asperger’s children show very disordered pragmatics of language, poor eye contact and social timing, little facial expression or gesture.
(7) Obsessive behaviour: Much or most of the behaviour described is carried out in an obsessive way, especially demand avoidance: as a result, most children show very low level achievement in school because motivation to avoid demands is so sustained, and because the child knows no boundaries to avoidance. Other obsessions tend to be social, i.e. to do with people and their characteristics; some obsessionally blame or harass people they don’t like, or are overpowering in their liking for certain people; children may target other individual children.	Autistic children are also obsessive, but less so with social topics. They are not obsessively focused on demand avoidance, and do not use obsessions for manipulative purposes. Order, arrangements and perceptual fascinations.
(8) Neurological involvement: Soft neurological signs are seen in the form of clumsiness and physical awkwardness; crawling late or absent in more than half. Some have absences, fits, episodic dyscontrol, or generalised excitability. Not enough hard evidence as yet.	Some comparable involvement in autism; less in terms of crawling and episodic dyscontrol.