These questions have been answered by Pat Smith, Specialist Child Psychologist, Head of Elizabeth Newson Centre, NORSACA.


Q. Is PDA part of the autistic spectrum?

A. This question addresses very directly the confusion that some professionals and parents experience and is difficult to provide a satisfactory answer without understanding the historical context around PDA (which I think that Phil Christie has addressed in his response to several of these questions). The first paper by Elizabeth Newson and her colleagues that appeared in a professional journal and that was peer reviewed was published in 2003. PDA is therefore seen by many clinicians as a relatively new condition, despite the earlier descriptions that resonated with parents, teachers and other professionals and there has been on-going controversy about where the PDA profile fits in standard diagnostic systems. Over time PDA has been increasingly seen as part of the autism spectrum by more professionals and clinicians. The research completed at the Institute of Psychiatry has supported this broader understanding. Liz O’Nions’ paper that was recently published in the Journal of Child Psychology and Psychiatry describing the development of the Extreme Demand Avoidance Questionnaire (EDA-Q) shows significant potential as a tool to assist in the identification of children with a PDA profile.

At the Elizabeth Newson Centre, when we see a child who we feel matches the PDA profile we would in the first instance look at how that individual child’s profile would fit within the autism spectrum and then discuss that within this, there are certain sub - groups that have been described and that our view would be that for this child’s profile the best fit seems to be PDA. We often see children and young people who clinicians have found confusing and as a consequence they have been misunderstood and their needs unmet. Understanding the child and signposting the approaches that are necessary to support them is often easier once a diagnostic opinion has been arrived at.

Q. What are the differences between PDA and Personality Disorders?

A. Many conditions are defined by a set of behavioural features and where this is the case there are often areas of overlap, connection and interconnection. Phil Christie describes this in some detail in his response to the question he has answered about PDA, ODD and Attachment Disorder.

For the diagnosis of a personality disorder to be considered four defining features need to be evident. These are:

  1. Distorted thinking patterns,
  2. Problematic emotional responses,
  3. Over- or under-regulated impulse control, and
  4. Interpersonal difficulties.

These four core features are common to all personality disorders and before a diagnosis is made, a person must demonstrate significant and enduring difficulties in at least two of those four areas: Furthermore, personality disorders are not usually diagnosed in children because of the requirement that personality disorders represent enduring problems across time. These four key features combine in various ways to form ten specific personality disorders identified in DSM-5 (APA, 2013). Each disorder lists a set of criteria reflecting observable characteristics associated with that disorder. In order to be diagnosed with a specific personality disorder, a person must meet the minimum number of criteria established for that disorder. Furthermore, to meet the diagnostic requirements for a psychiatric disorder, the symptoms must cause functional impairment and/or subjective distress. This means the symptoms are distressing to the person with the disorder and/or the symptoms make it difficult for them to function well in society.

Aspects of personality disorder can present in a similar way to those features that make up the profile of PDA.  Again there is also the possibility of the co-existence or ‘co-morbidity’ of different conditions leading particularly complex presentation.

There is very little research pertaining to Autism and Personality Disorders let alone PDA. There is an interesting Occasional Paper (number77) published in 2011 by the Royal College of Psychiatrists titled ‘Developing services to improve the quality of life of young people with neurodevelopmental disorders, emotional/neurotic disorders and emerging personality disorder’. This paper attempts to highlight that evidence based, cost –effective treatments for conditions such as personality disorder as well as for neurodevelopmental disorders such as autism exist but commissioners and clinicians may not be aware of them. Surprisingly the paper has little to say about the complexities around developing a robust diagnostic opinion and particular concerns would centre around the possibility of behavioural profiles being interpreted in a range of different ways. This highlights the need to complete detailed assessments.

It is essential that these comprehensive assessments include the taking of a detailed developmental history in order to understand not only how a young adult presents now but how they developed through their childhood. This together with detailed observation, information from a range of settings, other professionals’ views and the careful consideration of all relevant factors and circumstances will help to establish a clearer understanding of an individual’s profile. Clearly this becomes a more complex task even for experienced practitioners as children grow into young people and information is often more difficult to access.

Without this robust approach to assessment there remains the possibility that, for whatever reason, a child whose neurodevelopmental diagnosis was missed may later be described in terms of personality disorder as a young adult.  

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