Thread by @Richard_Autism

@NeurodiverseFa1 Firstly, there is much bold (I would say erroneous) claims being made about PDA. There is no agreement over what PDA, & what features are associated with PDA; it is highly contested & substantially controversial topic.

@NeurodiverseFa1 This is a short essay covering core PDA debates.
researchgate.net/publication/35…

@NeurodiverseFa1 This video covers the core PDA debates, around what it is in great detail here.

@NeurodiverseFa1 These debates matter as some topic experts opinions & evidence suggest at least some aspects of PDA can be explained/ predicted by ADHD itself. That PDA is a pseudo-syndrome, i.e., not a distinct diagnostic category.

@NeurodiverseFa1 So the short answer to:

Is it a Co-morbid disorder that comes with ADHD?

Is depends on who you ask & when, as there is PDA is pretty much whatever a person wants it to be there.

@NeurodiverseFa1 An example, there are wildly different diagnostic thresholds for PDA within the PDA literature & clinical practice with PDA is highly diverse.

I explain this here:
rationaldemandavoidance.com/2021/04/25/pda…

@NeurodiverseFa1 So what I am going to do is try & detail what the literature states about PDA & cut through the apparent nonsense ("bullshit") that surrounds PDA.

@NeurodiverseFa1 An example the PDA Society has produced this document on how to assess for PDA, it is a highly problematic, highly biased document, based on view of 12 clinicians, 11 of which are based in private practice.
pdasociety.org.uk/wp-content/upl…

@NeurodiverseFa1 Here is a thread where I deconstruct much of the bold claims made by the PDA Society in the above document & pointing out information which contradicts it.
…emandavoidancecom.files.wordpress.com/2022/05/02-feb…

@NeurodiverseFa1 "Attention Deficit Hyperactivity Disorder (ADHD) – when individuals may be unable to follow requests or instructions due to poor executive function and impulse control." PDA Society 2022, p14.
Charity is claiming that PDA demand-avoidance is different from PDA.

@NeurodiverseFa1 I doubt this is the case for multiple reasons. First one is that there is strong overlap between many features of PDA & features assessed in ADHD questionnaires, like the Connor's Scale.

@NeurodiverseFa1 As I said previously, there is also topic experts opinion & opinion & research which suggests some PDA features can be explained/ predicted by ADHD.

@NeurodiverseFa1 An example contradicting PDA Society's claim which is based on the opinion of those 12 highly biased clinicians, is this cross sectional study below:
ethos.bl.uk/OrderDetails.d…

@NeurodiverseFa1 "EF was significantly related to global PDA traits in the context of ASD, as well as to dimensional measures of specific associated behaviours such as emotional dysregulation and behavioural noncompliance...

@NeurodiverseFa1 ... Executive Function accounted for a significant proportion of the variance (r2 = 34%) in PDA traits." Goodson 2018, p64.

@NeurodiverseFa1 This matters in context of how overlap between ADHD & PDA has been noted in the literature since 2003.

@NeurodiverseFa1 "From the authors' descriptions, the impression is that these children are likely to have had co-morbid developmental and psychiatric problems, varyingly including oppositional defiant and/or hyperkinetic disorder or social anxiety disorder of childhood." Garralda 2003.

@NeurodiverseFa1 Link to Garralda 2003 below:
adc.bmj.com/content/88/7/5…

@NeurodiverseFa1 Others have also acknowledged that PDA features seem to overlap ADHD features.

See the below images for how PDA can be modelled as a pseudo-syndrome.

Image 1 is from O'Nions 2013, p93.
Image 2 is from Soppitt 2021, p299.
Image 3 is from Woods 2021, p12.

@NeurodiverseFa1 I should add that an obvious reason for overlap between PDA & ADHD is that both constructs have impulsive elements about them.

"Lability of mood, impulsive, led by need to control" Newson et al 2003, 597.
"Experiences excessive mood swings and impulsivity" Green et al 2018, p3

@NeurodiverseFa1 I am mentioning the previous point, because I suspect one could argue PDA is a subgroup of ADHD, instead of autism. Heck, I might even do that in my next conference talk to test if it can be argued.

@NeurodiverseFa1 I have already shown if one accepts underlying assumptions behind "PDA Profile of ASD", PDA would be a Neurodevelopmental Disorder, instead of "Profile".

I did that here:
researchgate.net/publication/36…

@NeurodiverseFa1 I should be clear, underlying assumptions for "PDA Profile of ASD", are not universally accepted. Many bold claims surrounding PDA are not widely accepted, example, there is much ongoing debate over breadth of autism, i.e., it remains to be seen autism has exanded to include PDA.

@NeurodiverseFa1 I am also asking if people want PDA features to be associated with autism, because there are many problematic/ atrociously described behaviours in PDA diagnostic/ screening tools. There is at least some demand they are not associated with autism, e.g., see below image.

@NeurodiverseFa1 I apologise if this seems like I am going on off loads tangents, but it is ALL. There is strong uncertainty over what PDA is & I am strongly trying to convey that to you.

@NeurodiverseFa1 I am going to continue with other empirical evidence in relation to PDA & ADHD that I am aware of.

@NeurodiverseFa1 "Further ongoing work by Kaushik (RCPsych CAP Faculty Annual Conference 2015 proceedings) has recognised that there are also associations between PDA, ADHD, and conduct disorder," Flackhill et al 2017, p65.

@NeurodiverseFa1 "Results
Eleven children (44%) scored above cut-off on the EDA-Q, 3 of which were diagnosed with ASD (43% of children with ASD). PDA was best predicted by a combination of high SDQ peer score (OR=3.5) and low prosocial score (OR=0.59)...

@NeurodiverseFa1 ... Of the DAWBA dimensions, OCD (p = 0.027), oppositionality (p = 0.017) and conduct problems (p= 0.035) were predictive of PDA."
Kaushik et al 2015, p8.

@NeurodiverseFa1 Kaushik et al (2015) data is what is referred to Flackhill e t al (2017).

Link to Flackhill et al (2017) below:
ingentaconnect.com/contentone/bil…

@NeurodiverseFa1 "High SDQ conduct and hyperactivity scores plus a clinical diagnosis of anxiety were highly predictive of scores above the pathological demand avoidance threshold on the EDA-Q (area under the receiver operator characteristic curve of 0·84, sensitivity 62%, specificity 78%)...

@NeurodiverseFa1 ... These findings suggest that pathological demand avoidance presentations can be successfully explained through a combination of currently accepted comorbid diagnoses."
Green et al 2018a, pp.7-8.

@NeurodiverseFa1 Link to Green et al 2018a is below
thelancet.com/journals/lanch…

@NeurodiverseFa1 "Outcomes and results:
Many of these constructs, but particularly ADHD (r = 0.71, p<0.001) were significant correlates of PDA, the correlation between ASD and PDA was small, and did not predict PDA...

@NeurodiverseFa1 ...Multiple regression indicated that a combination of higher attention deficit, antagonism, and lower emotional stability predicted 65 % of an individual’s PDAscore, but that their PDA score did not contribute to the prediction of delinquency."
Egan et al 2020, p1.

@NeurodiverseFa1 Link to Egan et al 2020 is below:
sciencedirect.com/science/articl…

@NeurodiverseFa1 There are various studies populations which report ADHD diagnoses present. Assuming PDA is a distinct diagnostic construct, would provide evidence PDA & ADHD can co-occur together.

@NeurodiverseFa1 An example of one study.
"Over half of the cohort (54.4%) reported a formal prior mental health diagnosis: 97 (28%) depression; 58 (16.7%) an ASD diagnosis; 53 (15.3%) an anxiety disorder; 28 (8.1%) ADHD/ADD; 24 (6.9%)..."
Egan et al 2019, p3.

@NeurodiverseFa1 Link to Egan et al 2019 is below
link.springer.com/article/10.100…

@NeurodiverseFa1 "...significant symptoms of PDA, the four children met criteria for a range of neurobehavioural disorders; all four had cognitive impairment (IQ < 85) and met DSM-IV-TR criteria for ADHD. Three, in addition, met criteria for ASD and Developmental Coordination Disorder
(DCD)..."

@NeurodiverseFa1 Above quote is from Reilly et al 2014, p1.

Reilly et al 2014, discusses 4 case studies with epilepsy & their co-occurring difficulties. One should notice, ALL 4 had ADHD diagnoses, while ONLY 3 had autism diagnoses. Indicating ADHD & PDA can co-occur SEPARATELY from autism.

@NeurodiverseFa1 Link to Reilly et al 2014 article is below
sciencedirect.com/science/articl…

@NeurodiverseFa1 "Case study: Jack (fictitious name)
Jack is a seven year old boy diagnosed with PDA and Attention Deficit Hyperactivity Disorder (ADHD)."
Carlile 2011, p52.

Case study diagnosed with PDA & ADHD, and NOT autism, although paper suggests PDA might be an autism subgroup.

@NeurodiverseFa1 Link to Carlile 2011 case study is below
ingentaconnect.com/contentone/bil…

@NeurodiverseFa1 Final case study of PDA & ADHD.
"Mr S has previously been diagnosed with ADHD and dyslexia. He currently has no mental health or PD diagnosis."
Trundle et al 2017, p19.

@GraceTrundle has informed me the ADHD diagnosis was removed at later date.

@NeurodiverseFa1 @GraceTrundle About a third of CYP diagnosed with ADHD no longer meet threshold for ADHD into adulthood. So not sure one can read too much into ADHD diagnosis later being removed.

Also @GraceTrundle informed me case study was NOT assessed for autism!

@NeurodiverseFa1 @GraceTrundle Link to Trundle et al 2017 case study:
dx.doi.org/10.1108/JIDOB-…

@NeurodiverseFa1 @GraceTrundle I think that is everything off the top of my head. I did search some later studies & other case studies for ADHD. That should be a comprehensive overview of evidence & debates around PDA & ADHD.

@GraceTrundle feel free to correct me if you think I am missing anything.

@NeurodiverseFa1 @GraceTrundle It seems that PDA can be validly modelled as a pseudo-syndrome with some of its features being explained/ attributed to ADHD. If one assumes PDA is a distinct diagnostic category, PDA & ADHD can co-occur together & apparently independently (separate) of autism!

@NeurodiverseFa1 @GraceTrundle This is to remind me to do a conference talk arguing that PDA is an ADHD subtype. It would be to test that PDA can be modelled that way.

@NeurodiverseFa1 @GraceTrundle On that note, I am ending this thread.

@threadreaderapp please can you unroll.

Thank you in advance.

@NeurodiverseFa1 @GraceTrundle Sorry, I just remembered McFazden (2020), it seems to have some relevant info in.

Link to it below:
summit.sfu.ca/item/20830

& here as well
books.google.co.uk/books/about/Ex…

@NeurodiverseFa1 @GraceTrundle "PDA remains controversial. Some professionals recognize PDA while others reject its existence and insist that the symptoms are the result of other similar and already established behavior disorders such as Attention Deficit Hyperactivity Disorder (ADHD) or conduct disorder." p5.

@NeurodiverseFa1 @GraceTrundle "A sample of 78 participants responded to an on-line questionnaire that collected information on the presence of PDA. There was a statistically significant difference in the PDA scores for children with and without a clinical diagnosis (autism, ADHD, anxiety)." McFazden 2020, pIV

@NeurodiverseFa1 @GraceTrundle "Children diagnosed with autism had significantly different (higher) PDA scores than children without autism. No other comparisons were significant."

Argues it means PDA is an autism subgroup. It could be that PDA presents differently in autistic persons vs non-autistic persons.

@NeurodiverseFa1 @GraceTrundle Considering autism often interacts with co-occurring difficulties, which means that co-occurring difficulties/ diagnoses often present differently in autistic persons vs non-autistic persons. That autistic co-occurring difficulties can have different causal mechanisms.

@NeurodiverseFa1 @GraceTrundle This stuff is touched upon "critical" PDA literature, like Green et al (2018a) & Kildahl et al (2021).

One would predict PDA presents slightly differently in autistic persons vs non-autistic persons. PDA might have different causal mechanisms in autistic persons.

@NeurodiverseFa1 @GraceTrundle This paper by @hegel_eva & Vicente does an excellent job discussing how autism & co-occurring difficulties often interact. I suggest the paper is relevant to PDA. tandfonline.com/doi/abs/10.108…

@NeurodiverseFa1 @GraceTrundle Back to McFazden (2020).
"In the sample of seventy-eight (78) respondents, 24 (31%) reported scores on the EDA-Q high enough for their child to be considered as having a PDA profile as seen in table 4.6." McFazden 2020, p26.

@NeurodiverseFa1 @GraceTrundle "Twenty-nine (29) respondents reported a child’s diagnosis of ADHD and of those, 10 children or 34% presented with a PDA profile."
McFazden 2020, p26.

So that 34% of CYP meeting threshold on EDA-Q in this studies sample reported with ADHD.

@NeurodiverseFa1 @GraceTrundle "Fifteen (15) respondents reported that their child had no diagnosis (Typically Developing) and of those, 2 children or 13% presented with a PDA profile."
McFazden 2020, p26.

I am just noting the 2 typically developing CYP meeting threshold on EDA-Q for giggles. False positives?

@NeurodiverseFa1 @GraceTrundle "Children who were diagnosed with ASD had a higher score on the EDA-Q (M = 46.20, SD = 11.3) than children without ASD (M = 37.73, SD = 6.7); t (76) = -3.979, p < 01... The remaining t-tests were not significant"."
McFazden 2020, p27.

@NeurodiverseFa1 @GraceTrundle "In examining the ADHD profile there are two main areas that clinicians assess, inattention and hyperactivity/impulsivity (DSM-5, 2013), neither of which has been suggested as a part of the PDA profile." McFazden 2020, p30.

Author not reading relevant literature, like Garralda.

@NeurodiverseFa1 @GraceTrundle "The comorbidity rate in regard to anxiety disorder and ASD, and, anxiety disorder and ADHD was relatively high. Out of the anxiety group of twelve, five respondents also reported a diagnosis of ASD and five respondents reported a diagnosis of ADHD."
McFazden 2020, p30.

@NeurodiverseFa1 @GraceTrundle "Twelve (12) respondents reported a child’s diagnosis of anxiety and of those, 6 children or 50% presented with the PDA profile."
McFazden 2020, p26.

@NeurodiverseFa1 @GraceTrundle That is McFazden 2020.
I am going to see if Newson said about ADHD. She did write in one conference piece asking about ADHD. I need to find that piece.

@NeurodiverseFa1 @GraceTrundle "in attention, especially in school; however, observation
shows that 48% (study B) are definitely not flitting in hyperactive terms, and that 34% only show this behaviour when demands are being made on them...

@NeurodiverseFa1 @GraceTrundle ... Half of this group concentrate well when engaged in self-chosen interests (mainly dolls and video). Only 4% are hyperactive under whatever conditions they are observed."
Newson et al 2003, p598.

@NeurodiverseFa1 @GraceTrundle "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"
Newson et al 2003, p597

@NeurodiverseFa1 @GraceTrundle "Among the adult sample, parents were able to differentiate between impulsivity and lability of mood. Fourteen adults were both impulsive in behaviour and prone to mood swings, 12 of these individuals being capable of violencewhen angry...

@NeurodiverseFa1 @GraceTrundle ...Two had mood swings but were not impulsive (of whom both could be violent). One was impulsive without mood swings, and one was neither; these two were not violent to others, but both could be self-injurious. It seems that lability and impulsivity are lasting risks,...

@NeurodiverseFa1 @GraceTrundle ...though not necessarily appearing in every child;"
Newson et al 2003, p597.

So that is Newson discussing impulsive aspects of cases in her PDA cohort.

As I said McFazden was mistaken about people NOT suggesting a overlap between PDA & ADHD.

@NeurodiverseFa1 @GraceTrundle Bingo. Newson did question if at least one aspect of PDA was ADHD, unsure if referring to ADD subgroup.

Image is from Newson 1996, p20. It is of a graph showing data of number of cases which display "Flitting" behaviour, which was not universal among Newson's cases.

@NeurodiverseFa1 @GraceTrundle The conference paper seems not to be publicly available anymore via Autism East Midlands website, but the paper does exist.

@NeurodiverseFa1 @GraceTrundle Below screenshot is of @GraceTrundle 2017 paper, p25 referencing Newson 1996 conference paper.

@NeurodiverseFa1 @GraceTrundle I think I am done this time for good.

@threadreaderapp please can you unroll?

Thank you in advance.

@NeurodiverseFa1 @ReachoutASC @neuroteachers If I recall correctly, one of you two at some point wanted some information on PDA/ ADHD. Or failing that, actually, Catrina, did you co-author a paper with a case study with ADHD (which I have forgotten to include in evidence listed above)?

@NeurodiverseFa1 @GraceTrundle Sorry, there is one more case study, one by @neuroteachers.
"Jack was educated in a small, rural, mainstream Primary School in the South West England. He was initially diagnosed with autism and ADHD"
Lyle & Leatherland 2018, p34.

@NeurodiverseFa1 @GraceTrundle @neuroteachers "Jack scored 57, putting him well above the cut off point. We sent the results along with notes we had made during observations to a paediatrician who subsequently diagnosed Jack with Autism Spectrum Condition (ASC)...

@NeurodiverseFa1 @GraceTrundle @neuroteachers ... The descriptor ‘Extreme Demand Avoidant (EDA) behaviours’ was also added."
Lyle & Leatherland 2018, p35.

@NeurodiverseFa1 @GraceTrundle @neuroteachers Link to Lyle & Leatherland (2018) case study is below:
ingentaconnect.com/contentone/bil…

@NeurodiverseFa1 @GraceTrundle @neuroteachers Restating conclusion:
Seems that PDA can be validly modelled as a pseudo-syndrome with some of its features being explained/ attributed to ADHD. If one assumes PDA is a distinct diagnostic category, PDA & ADHD can co-occur together & apparently independently (separate) of autism!

@NeurodiverseFa1 @GraceTrundle @neuroteachers That should finally be it this time.

@NeurodiverseFa1 @GraceTrundle @neuroteachers Link to the threadreader app for these series of tweets. I did not ask it to unroll, as sometimes it does not capture all the tweets, if I stop/ start thread. All the tweets are there.
threadreaderapp.com/thread/1610293…