Sunday 15 May 2016

The difference between Pathological Demand Avoidance (PDA) and Oppositional Defiant Disorder (ODD)

What is the difference between ODD (Oppositional Defiant Disorder) and PDA (Pathological Demand Avoidance)? This is a question I have been asked many times over the past few years as people start to hear and see these acronyms more often.

Our daughter was diagnosed by a paediatrician at the young age of two and a half. Her actual diagnosis is written as:

1. Autistic Spectrum Disorder and
2. Oppositional behaviours/pathological demand avoidance behaviours.

After a few months of searching for general information on autism, we experienced our 'lightbulb moment' when we stumbled across Pathological Demand Avoidance (PDA). We could tick almost all of the diagnostic criteria for our girl; the language delay with catch-up was just one point which seemed particularly relevant for us.

She was passive, resisted demands, led by a need to control, sociable and comfortable with role-play. The last two characteristics were not often associated with other profiles of autism, and that is where we saw the most difference to other autistic children we knew.
Given that the word oppositional was used when she was first assessed, our daughter was perhaps lucky to escape the suggestion of Oppositional Defiant Disorder as a diagnosis. It wouldn't have been right, but it would have been an obvious choice. 

Oppositional our girl may have been, but she definitely wasn't defiant. She also wasn't naughty. When she was younger, there may not have seemed to be an obvious reason for her refusal to do the most basic of tasks, but we soon realised that there was usually an underlying cause. She didn't refuse to wear socks just because she wanted to be awkward, it was a sensory issue. She didn't get irrationally distressed when we walked a different way to nursery just to annoy us; her fear of not being in control and not knowing what was happening was the cause of that.

In fact, over time we have learned that some of her refusals are sensory led, but others are anxiety driven. Her worries about going to new places or her fear of being sick in the car prevent us from getting her out as much as we would like. Of course many children have these kinds of worries, but not all children are autistic. The difference we see in our younger daughter is the extreme distress which it causes her, and the long-lasting knock-on effects if we choose to force the issue.
Pathological Demand Avoidance is an Autism Spectrum Condition.
Oppositional Defiant Disorder is not an Autism Spectrum Condition.

So back to my original question: what is the difference between ODD (Oppositional Defiant Disorder) and PDA (Pathological Demand Avoidance)?

This diagram below, created by the PDA Society, shows that PDA falls within the blue circle of autism spectrum profiles, whereas ODD does not. There are a number of other conditions shown in the green outer circle that are also often diagnosed alongside autism but can be stand-alone diagnoses.
With thanks to the PDA Society for creating this slide and allowing me to share

A child (or adult) can be given an ODD diagnosis without an autism diagnosis; however every child/adult diagnosed with PDA is autistic. 

It would be unlikely I feel (though maybe not impossible), to have a child diagnosed with PDA and ODD. Because Pathological Demand Avoidance is not yet recognised everywhere, I think some children are given a diagnosis of ODD alongside a diagnosis of autism. The trouble with an ODD diagnosis when PDA would be a better fit for a child is that there is a huge difference in the strategies which are proven successful for PDA versus ODD. ODD strategies are all about strict discipline and traditional parenting methods, such as rewards and consequences. These have been shown to be generally ineffective for PDA individuals. They may work once or twice if all other conditions are favourable, but not when the need to avoid demands is strong. If strategies for ODD have been tried with a child and are not working, it would be worth taking a look at different parenting style that seem to work better with PDA. My post Strategies for PDA gives a starting point, and I would also suggest checking out helpful approaches listed on the PDA Society page, or the Behavioural Strategies leaflet produced by Autism West Midlands.

Children with ODD are often described as having 'emotional and behavioural difficulties', or 'conduct problems'. They may have experienced difficult social environments and use behaviour as a means of attention, an outpouring for their anger or to hide their lack of self-worth. One difference often quoted between those with ODD or PDA is that children with ODD are less likely to embarrass themselves in front of their peers. PDA children on the other hand are more likely to have unpredictable outbursts, even in front of their peers. They often attempt to control all social interaction but fail to understand why this might upset their peers and leads to the PDAers being shunned.

Contact's website has more information on Conduct Disorder and Oppositional Defiant Disorder, and there is also a good summary of ODD over on the Good Schools Guide website.

The term 'can't, not won't' is often used to describe PDA, meaning that a child can't help the fact that they won't do something, and thinking of that can help to change mindset and realise that a different approach is needed. 

This is a topic which is likely to continue to draw much further discussion over the coming years; it is not a clear cut area. Remember that most parents are experts in their own children. Go with your gut instinct and what works for your child and your family. A diagnosis of PDA can help educate others about your child's needs, but every child is an individual so it is important to look at their needs in detail. A PDA diagnosis might explain why you have chosen to parent in a manner that many would see as not typical, but more important is trying to ensure that all those around your child are using helpful and consistent strategies.

For more information about PDA, please read any of the books in my post

Books about the Pathological Demand Avoidance (PDA) profile of autism

Stack of book spines, all books about PDA listed in the post link given

To find out more about our experiences, please check out our 'About Us' page or the summary of our experience in Our PDA Story Week 35. If you are looking for more online reading about Pathological Demand Avoidance, the posts below may help.

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