“Charlie” is an eight-year-old child with autism. Her parents are worried because she often responds to requests with insults, aggression and refusal. Simple demands, such as being asked to get dressed, can trigger an intense need to control the situation, fights and meltdowns.

Charlie’s parents find themselves in a constant cycle of conflict, trying to manage her and their own reactions, often unsuccessfully. Their attempts to provide structure and consequences are met with more resistance.

What’s going on? What makes Charlie’s behaviour – that some are calling “pathological demand avoidance” – different to the defiance most children show their parents or carers from time-to-time?

What is pathological demand avoidance?

British developmental psychologist Elizabeth Newson coined the term “pathological demand avoidance” (commonly shortened to PDA) in the 1980s after studying groups of children in her practice.

A 2021 systematic review noted features of PDA include resistance to everyday requests and strong emotional and behavioural reactions.

Children with PDA might show obsessive behaviour, struggle with persistence, and seek to control situations. They may struggle with attention and impulsivity, alongside motor and coordination difficulties, language delay and a tendency to retreat into role play or fantasy worlds.

PDA is also known as “extreme demand avoidance” and is often described as a subtype of autism. Some people prefer the term persistent drive for autonomy or pervasive drive for autonomy.

What does the evidence say?

Every clinician working with children and families recognises the behavioural profile described by PDA. The challenging question is why these behaviours emerge.

PDA is not currently listed in the two diagnostic manuals used in psychiatry and psychology to diagnose mental health and developmental conditions, the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the World Health Organization’s International Classification of Diseases (ICD-11).

Researchers have reported concerns about the science behind PDA. There are no clear theories or explanations of why or how the profile of symptoms develop, and little inclusion of children or adults with lived experience of PDA symptoms in the studies. Environmental, family or other contextual factors that may contribute to behaviour have not been systematically studied.

A major limitation of existing PDA research and case studies is a lack of consideration of overlapping symptoms with other conditions, such as autism, attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, anxiety disorder, selective mutism and other developmental disorders. Diagnostic labels can have positive and negative consequences and so need to be thoroughly investigated before they are used in practice.

Classifying a “new” condition requires consistency across seven clinical and research aspects: epidemiological data, long-term patient follow-up, family inheritance, laboratory findings, exclusion from other conditions, response to treatment, and distinct predictors of outcome. At this stage, these domains have not been established for PDA. It is not clear whether PDA is different from other formal diagnoses or developmental differences.

Finding the why

Debates over classification don’t relieve distress for a child or those close to them. If a child is “intentionally” engaged in antisocial behaviour, the question is then “why?”

Beneath the behaviour is almost always developmental difference, genuine distress and difficulty coping. A broad and deep understanding of developmental processes is required.

Interestingly, while girls are “under-represented” in autism research, they are equally represented in studies characterising PDA. But if a child’s behaviour is only understood through a “pathologising” or diagnostic lens, there is a risk their agency may be reduced. Underlying experiences of distress, sensory overload, social confusion and feelings of isolation may be missed.

So, what can be done to help?

There are no empirical studies to date regarding PDA treatment strategies or their effectiveness. Clinical advice and case studies suggest strategies that may help include:

• reducing demands
• giving multiple options
• minimising expectations to avoid triggering avoidance
• engaging with interests to support regulation.

Early intervention in the preschool and primary years benefits children with complex developmental differences. Clinical care that involves a range of medical and allied health clinicians and considers the whole person is needed to ensure children and families get the support they need.

It is important to recognise these children often feel as frustrated and helpless as their caregivers. Both find themselves stuck in a repetitive cycle of distress, frustration and lack of progress. A personalised approach can take into account the child’s unique social, sensory and cognitive sensitivities.

In the preschool and early primary years, children have limited ability to manage their impulses or learn techniques for managing their emotions, relationships or environments. Careful watching for potential triggers and then working on timetables and routines, sleep, environments, tasks, and relationships can help.

As children move into later primary school and adolescence, they are more likely to want to influence others and be able to have more self control. As their autonomy and ability to collaborate increases, the problematic behaviours tend to reduce.

Strategies that build self-determination are crucial. They include opportunities for developing confidence, communication and more options to choose from when facing challenges. This therapeutic work with children and families takes time and needs to be revisited at different developmental stages. Support to engage in school and community activities is also needed. Each small step brings more capacity and more effective ways for a child to understand and manage themselves and their worlds.

What about Charlie?

The current scope to explain and manage PDA is limited. Future research must include the voices and views of children and adults with PDA symptoms.

Such emotional and behavioural difficulties are distressing and difficult for children and families. They need compassion and practical help.

For a child like Charlie, this could look like a series of sessions where she and her parents meet with clinicians to explore Charlie’s perspective, experiences and triggers. The family might come to understand that, in addition to autism, Charlie has complex developmental strengths and challenges, anxiety, and some difficulties with adjustment related to stress at home and school. This means Charlie experiences a fight, flight, freeze response that looks like aggression, avoidance or shutting down.

With carefully planned supports at home and school, Charlie’s options can broaden and her distress and avoidance can soften. Outside the clinic room, Charlie and her family can be supported to join an inclusive local community sporting or creative activity. Gradually she can spend more time engaged at home, school and in the community.

Nicole Rinehart, Professor, Child and Adolescent Psychology, Director, Krongold Clinic (Research), Monash University; David Moseley, Senior Research Fellow, Deputy Director (Clinical), Monash Krongold Clinic, Monash University, and Michael Gordon, Associate Professor, Psychiatry, Monash University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Flavoured nicotine pouches are being promoted to young people on social media platforms such as TikTok and Instagram.

Although some viral videos have been taken down following a series of reports in The Guardian, clips featuring Australian influencers have claimed nicotine pouches are a safe and effective way to quit vaping. A number of the videos have included links to websites selling these products.

With the rapid rise in youth vaping and the subsequent implementation of several reforms to restrict access to vaping products, it’s not entirely surprising the tobacco industry is introducing more products to maintain its future revenue stream.

The major trans-national tobacco companies, including Philip Morris International and British American Tobacco, all manufacture nicotine pouches. British American Tobacco’s brand of nicotine pouches, Velo, is a leading sponsor of the McLaren Formula 1 team.

But what are nicotine pouches, and are they even legal in Australia?

Like snus, but different

Nicotine pouches are available in many countries around the world, and their sales are increasing rapidly, especially among young people.

Nicotine pouches look a bit like small tea bags and are placed between the lip and gum. They’re typically sold in small, colourful tins of about 15 to 20 pouches. While the pouches don’t contain tobacco, they do contain nicotine that is either extracted from tobacco plants or made synthetically. The pouches come in a wide range of strengths.

As well as nicotine, the pouches commonly contain plant fibres (in place of tobacco, plant fibres serve as a filler and give the pouches shape), sweeteners and flavours. Just like for vaping products, there’s a vast array of pouch flavours available including different varieties of fruit, confectionery, spices and drinks.

The range of appealing flavours, as well as the fact they can be used discreetly, may make nicotine pouches particularity attractive to young people.

Users absorb the nicotine in their mouths and simply replace the pouch when all the nicotine has been absorbed. Tobacco-free nicotine pouches are a relatively recent product, but similar style products that do contain tobacco, known as snus, have been popular in Scandinavian countries, particularly Sweden, for decades.

Snus and nicotine pouches are however different products. And given snus contains tobacco and nicotine pouches don’t, the products are subject to quite different regulations in Australia.

What does the law say?

Pouches that contain tobacco, like snus, have been banned in Australia since 1991, as part of a consumer product ban on all forms of smokeless tobacco products. This means other smokeless tobacco products such as chewing tobacco, snuff, and dissolvable tobacco sticks or tablets, are also banned from sale in Australia.

Tobacco-free nicotine pouches cannot legally be sold by general retailers, like tobacconists and convenience stores, in Australia either. But the reasons for this are more complex.

In Australia, under the Poisons Standard, nicotine is a prescription-only medicine, with two exceptions. Nicotine can be used in tobacco prepared and packed for smoking, such as cigarettes, roll-your-own tobacco, and cigars, as well as in preparations for therapeutic use as a smoking cessation aid, such as nicotine patches, gum, mouth spray and lozenges.

If a nicotine-containing product does not meet either of these two exceptions, it cannot be legally sold by general retailers. No nicotine pouches have currently been approved by the Therapeutic Goods Administration as a therapeutic aid in smoking cessation, so in short they’re not legal to sell in Australia.

However, nicotine pouches can be legally imported for personal use only if users have a prescription from a medical professional who can assess if the product is appropriate for individual use.

We only have anecdotal reports of nicotine pouch use, not hard data, as these products are very new in Australia. But we do know authorities are increasingly seizing these products from retailers. It’s highly unlikely any young people using nicotine pouches are accessing them through legal channels.

Health concerns

Nicotine exposure may induce effects including dizziness, headache, nausea and abdominal cramps, especially among people who don’t normally smoke or vape.

Although we don’t yet have much evidence on the long term health effects of nicotine pouches, we know nicotine is addictive and harmful to health. For example, it can cause problems in the cardiovascular system (such as heart arrhythmia), particularly at high doses. It may also have negative effects on adolescent brain development.

The nicotine contents of some of the nicotine pouches on the market is alarmingly high. Certain brands offer pouches containing more than 10mg of nicotine, which is similar to a cigarette. According to a World Health Organization (WHO) report, pouches deliver enough nicotine to induce and sustain nicotine addiction.

Pouches are also being marketed as a product to use when it’s not possible to vape or smoke, such as on a plane. So instead of helping a person quit they may be used in addition to smoking and vaping. And importantly, there’s no clear evidence pouches are an effective smoking or vaping cessation aid.

Further, some nicotine pouches, despite being tobacco-free, still contain tobacco-specific nitrosamines. These compounds can damage DNA, and with long term exposure, can cause cancer.

Overall, there’s limited data on the harms of nicotine pouches because they’ve been on the market for only a short time. But the WHO recommends a cautious approach given their similarities to smokeless tobacco products.

For anyone wanting advice and support to quit smoking or vaping, it’s best to talk to your doctor or pharmacist, or access trusted sources such as Quitline or the iCanQuit website.

Becky Freeman, Associate Professor, School of Public Health, University of Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.