Babies born with high levels of bad cholesterol face a heightened risk for social and psychological problems in childhood


Babies born with high levels of bad cholesterol and a certain type of fat may face a heightened risk for social and psychological problems in childhood, according to new scientific findings.

In a study involving 1,369 children tracked from birth to 5 years of age, psychological scientists found that results of a standard blood test taken at birth could predict how teachers rated the children on emotion regulation, self-awareness, and interpersonal behavior 5 years later.

The results are published in Psychological Sciencee.

Researchers Erika M. Manczak of the University of Denver and Ian Gotlib of Stanford University were specifically interested in looking at the long-term implications of infants’ lipid profiles — a measurement of the amount of cholesterol and triglycerides in the blood.

Triglycerides are fats that, at high levels, can increase the risk of stroke and heart disease.

Manczak and Gotlib used data from an ongoing study involving children born in the town of Bradford in the United Kingdom between March 2007 and December 2010.

They looked at data involving 1,369 children from birth to 5 years of age. The babies were born to mothers of various ethnic backgrounds.

When the children reached age 3, the mothers were asked to rate their child’s health. And when the children were 4 to 5 years old, their teachers rated each of them on their psychological development, including self-confidence, emotional control, and interpersonal relationships.

The teachers were asked to classify each child as below, at, or exceeding developmental expectations.

Manczak and Gotlib found that newborns’s whose cord blood showed high levels of high-density lipoprotein (HDL)–known as the “good cholesterol” because it removes fat from artery walls–were significantly more likely to later receive higher ratings on psychological development by their teachers.

In contrast, newborns whose cord blood tested high for triglycerides and very-low-density lipoprotein–known as the bad cholesterol–were more likely to receive low teacher ratings on social and emotional development. The results were consistent across ethnic groups and gender.

Manczak and Gotlib found that newborns’s whose cord blood showed high levels of high-density lipoprotein (HDL)–known as the “good cholesterol” because it removes fat from artery walls–were significantly more likely to later receive higher ratings on psychological development by their teachers.

Manczak and Gotlib acknowledge that their findings are correlational and don’t conclusively show that lipids in cord blood lead to psychological problems over time.

But the results do introduce the possibility that lipids may be a new mechanism to consider when trying to understand the causes of mental health problems, they say.

“If this is replicated in other studies, it would suggest that lipid profiles at birth could play a role in identifying children who might be at heightened risk for psychological problems later, allowing health care providers to intervene early,” Manczak says.

“It also introduces the possibility that lipids may be a new mechanism to consider when trying to understand what causes mental health problems.”

Mental health disorders (MHD) are very common in childhood and they include emotionalobsessive-compulsive disorder (OCD), anxiety, depression, disruptive (oppositional defiance disorder (ODD), conduct disorder (CD), attention deficit hyperactive disorder (ADHD) or developmental (speech/language delay, intellectual disability) disorders or pervasive (autistic spectrum) disorders[1].

Emotional and behavioural problems (EBP) or disorders (EBD) can also be classified as either “internalizing” (emotional disorders such as depression and anxiety) or “externalizing” (disruptive behaviours such as ADHD and CD). The terminologies of “problems” and “disorders” are interchangeably used throughout this article.

While low-intensity naughty, defiant and impulsive behaviour from time to time, losing one’s temper, destruction of property, and deceitfulness/stealing in the preschool children are regarded as normal, extremely difficult and challenging behaviours outside the norm for the age and level of development, such as unpredictable, prolonged, and/or destructive tantrums and severe outbursts of temper loss are recognized as behaviour disorders.

Community studies have identified that more than 80% of pre-schoolers have mild tantrums sometimes but a smaller proportion, less than 10% will have daily tantrums, regarded as normative misbehaviours at this age[2,3].

Challenging behaviours and emotional difficulties are more likely to be recognized as “problems” rather than “disorders” during the first 2 years of life[4].

Emotional problems, such as anxiety, depression and post-traumatic stress disorder (PTSD) tend to occur in later childhood. They are often difficult to be recognised early by the parents or other carers as many children have not developed appropriate vocabulary and comprehension to express their emotions intelligibly[5].

Many clinicians and carers also find it difficult to distinguish between developmentally normal emotions (e.g., fears, crying) from the severe and prolonged emotional distresses that should be regarded as disorders[6].

Emotional problems including disordered eating behaviour and low self-image are often associated with chronic medical disorders such as atopic dermatitis, obesity, diabetes and asthma, which lead to poor quality of life[79].

Identification and management of mental health problems in primary care settings such as routine Paediatric clinic or Family Medicine/General Practitioner surgery are cost-effective because of their several desirable characteristics that make it acceptable to children and young people (CYP) (e.g., no stigma, in local setting, and familiar providers). Several models to improve the delivery of mental health services in the Paediatric/Primary care settings have been recommended and evaluated recently, including coordination with external specialists, joint consultations, improved Mental Health training and more integrated on-site intervention with specialist collaboration[10,11].

A review of relevant published literature was conducted, including published meta-analyses and national guidelines. We searched for articles indexed by Ovid, PubMed, PubMed Medical Central, CINAHL, the Cochrane Database of Systematic reviews and other online sources. The searches were conducted using a combination of search expressions including “childhood”, “behaviour”, “disorders” or “problems”.


Various definitions for a wide range of childhood behavioural disorders are being used. The DSM-5[12] offers the commonest universally accepted standard criteria for the classification of mental and behaviour disorders. The ICD-10 is the alternative classification standard[13].

Challenging behaviours

Any abnormal pattern of behaviour which is above the expected norm for age and level of development can be described as “challenging behaviour”. It has been defined as: “Culturally abnormal behaviour (s) of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy or behaviour which is likely to seriously limit or deny access to and use of ordinary community facilities”[14]. They can include self-injury, physical or verbal aggression, non-compliance, disruption of the environment, inappropriate vocalizations, and various stereotypies. These behaviours can impede learning, restrict access to normal activities and social opportunities, and require a considerable amount of both manpower and financial resources to manage effectively.

Many instances of challenging behaviour can be interpreted as ineffective coping strategies for a young person, with or without learning disability (LD) or impaired social and communication skills, trying to control what is going on around them. Young people with various disabilities, including LD, Autism, and other acquired neuro-behavioural disorders such as brain damage and post-infectious phenomena, may also use challenging behaviour for specific purposes, for example, for sensory stimulation, gaining attention of carers, avoiding demands or to express their limited communication skills[15]. People who have a diverse range of neurodevelopmental disorders are more likely to develop challenging behaviours[16].

Some environmental factors have been identified which are likely to increase the risk of challenging behaviour, including places offering limited opportunities for making choices, social interaction or meaningful occupation. Other adverse environments are characterized by limited sensory input or excessive noise, unresponsive or unpredictable carers, predisposition to neglect and abuse, and where physical health needs and pain are not promptly identified. For example, the rates of challenging behaviour in teenagers and people in their early 20s is 30%-40% in hospital settings, compared to 5% to 15% among children attending schools for those with severe LD[15].

Aggression is a common, yet complex, challenging behaviour, and a frequent indication for referral to child and adolescent Psychiatrists. It commonly begins in childhood, with more than 58% of preschool children demonstrating some aggressive behaviour[17]. Aggression has been linked to several risk factors, including individual temperaments; the effects of disturbed family dynamics; poor parenting practices; exposure to violence and the influence of attachment disorders. No single factor is sufficient to explain the development of aggressive behaviour[18]. Aggression is commonly diagnosed in association with other mental health problems including ADHD, CD, ODD, depression, head injury, mental retardation, autism, bipolar disorder, PTSD, or dyslexia[19].

Disruptive behaviour problems

Disruptive behaviour problems (DBP) include attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and conduct disorder (CD). They constitute the commonest EBPs among CYP. Recent evidence suggests that DBPs should be regarded as a multidimensional phenotype rather than comprising distinct subgroups[20].

ADHD is the commonest neuro-behavioural disorder in children and adolescents, with prevalence ranging between 5% and 12% in the developed countries[21]. ADHD is characterized by levels of hyperactivity, impulsivity and inattention that are disproportionately excessive for the child’s age and development[12]. The ICD-10[13] does not use the term “ADHD” but “hyperkinetic disorder”, which is equivalent to severe ADHD. DSM-5 distinguishes between three subtypes of the disorder: predominantly hyperactive/impulsive, predominantly inattentive and combined types (Table ​(Table11).

Table 1

Subtypes of attention deficit hyperactivity disorder (based on DSM-5)

SubtypesPredominantly inattentive (ADD)Predominantly hyperactivity/ impulsivityCombined ADHD
Criteria6 of 9 inattentive symptoms6 of 9 hyperactivity/ impulsivity symptomsBoth criteria for (1) and (2)
DetailsFails to pay close attention to details or makes careless mistakesSquirms and fidgets
Has difficulty sustaining attentionCan’t stay seated
Does not appear to listenRuns/climbs excessively
Struggles to follow through on instructionsCan’t play/work quietly
Has difficulty with organization“On the go”/“driven by a motor”
Avoids or dislikes tasks requiring a lot of thinkingBlurts out answers
Loses thingsIs unable to wait for his turn
Is easily distractedIntrudes/interrupts others
Talks excessively
Other criteriaOnset before age of 12, lasting more than 6 mo, symptoms pervasive in 2 or more settings, causing significant impairment of daily functioning o development

ADHD: Attention deficit hyperactivity disorder.

CD refers to severe behaviour problems (Table ​(Table2),2), characterized by repetitive and persistent manifestations of serious aggressive or non-aggressive behaviours against people, animals or property such as being defiant, belligerent, destructive, threatening, physically cruel, deceitful, disobedient or dishonest, excessive fighting or bullying, fire-setting, stealing, repeated lying, intentional injury, forced sexual activity and frequent school truancy[13,22]. Children with CD often have trouble understanding how other people think, sometimes described as being callous-unemotional.

They may falsely misinterpret the intentions of other people as being mean. They may have immature language skills, lack the appropriate social skills to establish and maintain friendships, which aggravates their feelings of sadness, frustration and anger[12].

Table 2

DSM-5 definition of conduct disorder and oppositional defiant disorder

Oppositional defiant disorderConduct disorder
A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 mo as evidenced by at least four out of 8 symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a siblingA repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 mo from any of the categories below, with at least one criterion present in the past 6 mo
Aggression to people and animals: (1) Often bullies, threatens, or intimidates others; (2) Often initiates physical fights; (3) Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun); (4) Has been physically cruel to people; (5) Has been physically cruel to animals; (6) Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery); (7) Has forced someone into sexual activity
Angry/irritable mood: (1) Often loses temper; (2) Is often touchy or easily annoyed; (3) Is often angry and resentful
Argumentative/defiant behavior: (4) Often argues with authority figures or, for children and adolescents, with adults; (5) Often actively defies or refuses to comply with requests from authority figures or with rules; (6) Often deliberately annoys others; (7) Often blames others for his or her mistakes or misbehavior
Destruction of property: (8) Has deliberately engaged in fire setting with the intention of causing serious damage; (9) Has deliberately destroyed others’ property (other than by fire setting)
Deceitfulness or theft: (10) Has broken into someone else’s house, building, or car; (11) Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others); (12) Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)
Vindictiveness: (8) Has been spiteful or vindictive at least twice within the past 6 mo
Serious violations of rules: (13) Often stays out at night despite parental prohibitions, beginning before age 13 yr; (14) Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period; (15) Is often truant from school, beginning before age 13 yr
Note: The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic and the behavior should occur at least once per week for at least 6 mo
The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning
The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context (e.g., family, peer group, work colleagues), or it impacts negatively on social, educational, occupational, or other important areas of functioningIf the individual is age 18 yr or older, criteria are not met for antisocial personality disorder
Specify whether: Childhood-onset type (prior to age 10 yr); Adolescent-onset type or Unspecified onset
Specify if: With limited prosocial emotions: Lack of remorse or guilt; Callous-lack of empathy; Unconcerned about performance or Shallow or deficient affect
Specify current severity: Mild; Moderate or Severe
The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorderICD-10
It also requires the presence of three symptoms from the list of 15 (above), and duration of at least 6 mo. There are four divisions of conduct disorder: Socialised conduct disorder, unsocialised conduct disorder, conduct disorders confined to the family context and oppositional defiant disorder
Specify current severity: Mild; moderate or severe based on number of settings with symptoms shown

CD is the commonest reason for CYP referral for psychological and psychiatric treatment. Roughly 50% of all CYP with a MHD have a CD[23]. About 30%-75% of children with CD also have ADHD and 50% of them will also meet criteria for at least one other disorder including Mood, Anxiety, PTSD, Substance abuse, ADHD, learning problems, or thought disorders[24,25]. Majority of boys have an onset of CD before the age of 10 years, while girls tend to present mainly between 14 and 16 years of age[26]. Most CYP with CD grow out of this disorder, but a minority become more dissocial or aggressive and develop antisocial personality disorder as adults.

ODD is considered to be the mildest and commonest of the DBPs, with prevalence estimates of 6%-9% for pre-schoolers and boys outnumbering girls by at least two to one[27]. CYP with ODD are typically openly hostile, negativistic, defiant, uncooperative, and irritable. They lose their tempers easily and are mean and spiteful towards others (Table ​(Table2).2). They are mostly defiant towards authority figures, but they may also be hostile to their siblings or peers. This pattern of adversarial behaviour significantly negatively impact on their lives at home, school, and wider society, and seriously impairs all their relationships[28].

Emotional problems

Emotional problems in later childhood include panic disorder, generalized anxiety disorder (GAD), separation anxiety, social phobia, specific phobias, OCD and depression. Mild to moderate anxiety is a normal emotional response to many stressful life situations. Anxiety is regarded as a disorder when it is disproportionately excessive in severity in comparison to the gravity of the triggering circumstances, leading to abnormal disruption of daily routines. Panic disorder is characterized by panic attacks untriggered by external stimuli. GAD is characterized by generalized worry across multiple life domains. Separation anxiety disorder is characterized by fear related to actual or anticipated separation from a caregiver. Social anxiety disorder (also called social phobia), is characterized by fear of social situations where peers may negatively evaluate the person[12].

Common manifestations of Anxiety disorders include physical symptoms such as increased heart rate, shortness of breath, sweating, trembling, shaking, chest pain, abdominal discomfort and nausea[29]. Other symptoms include worries about things before they happen, constant concerns about family, school, friends, or activities, repetitive, unwanted thoughts (obsessions) or actions (compulsions), fears of embarrassment or making mistakes, low self-esteem and lack of self-confidence[30].

Depression often occurs in children under stress, experiencing loss, or having attentional, learning, conduct or anxiety disorders and other chronic physical ailments. It also tends to run in families[79,31].

Symptoms of depression are diverse and protean, often mimicking other physical and neurodevelopmental problems, including low mood, frequent sadness, tearfulness, crying, decreased interest or pleasure in almost all activities; or inability to enjoy previously favourite activities, hopelessness, persistent boredom; low energy, social isolation, poor communication, low self-esteem and guilt, feelings of worthlessness, extreme sensitivity to rejection or failure, increased irritability, agitation, anger, or hostility, difficulty with relationships, frequent complaints of physical illnesses such as headaches and stomach aches, frequent absences from school or poor performance in school, poor concentration, a major change in eating and/or sleeping patterns, weight loss or gain when not dieting, talk of or efforts to run away from home, thoughts or expressions of suicide or self-destructive behaviour[31].

Disruptive mood dysregulation disorder (DMDD) is a childhood disorder characterized by a pervasively irritable or angry mood recently added to DSM-5. The symptoms include frequent episodes of severe temper tantrums or aggression (more than three episodes a week) in combination with persistently negative mood between episodes, lasting for more than 12 mo in multiple settings, beginning after 6 years of age but before the child is 10 years old[32].

Autistic spectrum and pervasive development disorder

The definition of Autism has evolved over the years and has been broadened over time. DSM-IV-TR[33] and the ICD-10[13] defined the diagnostic category of pervasive developmental disorders (PDD) as the umbrella terminology used for a group of five disorders characterized by pervasive “qualitative abnormalities in reciprocal social interactions and in patterns of communication, and by a restricted, stereotyped, repetitive repertoire of interests and activities” affecting “the individual’s functioning in all situations”. These included autism, asperger syndrome, childhood disintegrative disorder (CDD), pervasive developmental disorder not otherwise specified (PDD-NOS) and Rett syndrome.

Autism and Asperger Syndrome are the most widely recognised and clinically diagnosed among this group of disorders. CDD is a term used to describe children who have had a period of normal development for the first 2-3 years before a relatively acute onset of regression and emergence of autistic symptoms. PDD-NOS was used, particularly in the United States, to describe individuals who have autistic symptoms, but do not meet the full criteria for Autism or Asperger’s Syndrome, denote a milder version of Autism, or to describe atypical autism symptoms emerging after 30 mo of age, and autistic individuals with other co-morbid disorders[34].

The category of PDD has been removed from DSM-5[12] and replaced with Autism Spectrum disorders (ASD). ASD (Table ​(Table3)3) is diagnosed primarily from clinical judgment usually by a multidisciplinary team, with minimal support from diagnostic instruments. Most individuals who received diagnosis based on the DSM-IV should still maintain their diagnosis under DSM-5, with some studies confirming that 91% to 100% of children with PDD diagnoses from the DSM-IV retained their diagnosis under the ASD category using the new DSM-5[35,36], while a systematic review has found a slight decrease in the rate of ASD with DSM-5[37].

Table 3

DSM-5 criteria for autism spectrum disorders

Persistent deficits in social communication and social interaction across multiple contexts, as manifested by 3 out 3 of the following, currently or by history
Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions
Deficits in nonverbal communicative behaviours used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication
Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers
Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two out of 4 of the following, currently or by history
Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases)
Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day)
Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest)
Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement)
Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life)
Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning
Specify if
With or without accompanying intellectual impairment With or without accompanying language impairment
Associated with a known medical or genetic condition or environmental factor
Specify current severity based on social communication impairments and restricted, repetitive patterns of behavior

There are many intervention approaches and strategies, used alone or in combination, for supporting individuals with ASD. These interventions need to individualized and be closely tailored to the level of social and linguistic abilities, cultural background, family resources, learning style and degree of communication skills[38].

Various communication enhancement strategies have been designed to manage ASD[39], including augmentative and alternative communication (AAC), Facilitated Communication, computer-based instruction and video-based instruction (Table ​(Table4).4). Several behavioural and psychological interventions (Table ​(Table5)5) have also been used successfully in managing ASD children, including applied behaviour analysis (ABA) and functional communication training (FCT)[40].

Table 4

Summary of common social communication enhancement strategies

Augmentative and alternative communicationSupplements/replaces natural speech and/or writing with aided [e.g., Picture Exchange Communication System, line drawings, Blissymbols, speech generating devices, and tangible objects] and/or unaided (e.g., manual signs, gestures, and finger spelling) symbols[39,129131]
Effective in decreasing maladaptive or challenging behaviour such as aggression, self-injury and tantrums, promotes cognitive development and improves social communication
Activity schedules/visual supportsUsing photographs, drawings, or written words that act as cues or prompts to help individuals complete a sequence of tasks/activities or behave appropriately in various settings[132]
Scripts are often used to promote social interaction, initiate or sustain interaction
Computer-/video-based instructionUse of computer technology or video recordings for teaching language skills, social skills, social understanding, and social problem solving[40]

Table 5

Summary of common behavioural modification strategies for management of childhood emotional and behavioural disorder

ABAUses principles of learning theory to bring about meaningful and positive change in behaviour, to help individuals build a variety of skills (e.g., communication, social skills, self-control, and self-monitoring) and help generalize these skills to other situations[122,123]
Discrete trial trainingA one-to-one instructional approach based on ABA to teach skills in small, incremental steps in a systematic, controlled fashion, documenting stepwise clearly identified antecedent and consequence (e.g., reinforcement in the form of praise or tangible rewards) for desired behaviours[40]
Functional communication trainingCombines ABA procedures with communicative functions of maladaptive behaviour to teach alternative responses and eliminate problem behaviours[124]
Pivotal response treatmentA play-based, child-initiated behavioural treatment, designed to teach language, decrease disruptive behaviours, and increase social, communication and academic skills, building on a child’s initiative and interests[125]
Positive behaviour supportUses ABA principles with person-centred values to foster skills that replace challenging behaviours with positive reinforcement of appropriate words and actions. PBS can be used to support children and adults with autism and problem behaviours[126]
Self-managementUses interventions to help individuals learn to independently regulate, monitor and record their behaviours in a variety of contexts, and reward themselves for using appropriate behaviours. It’s been found effective for ADHD and ASD children[127]
Time delayIt gradually decreases the use of prompts during instruction over time. It can be used with individuals regardless of cognitive level or expressive communication abilities[40]
Incidental teachingUtilizes naturally occurring teaching opportunities to reinforce desirable communication behaviour[128]
Anger managementVarious strategies can be used to teach children how to recognise the signs of their growing frustration and learn a range of coping skills designed to defuse their anger and aggressive behaviour, teach them alternative ways to express anger, including relaxation techniques and stress management skills

ABA: Applied behaviour analysis; ADHD: Attention deficit hyperactivity disorder; ASD: Autistic spectrum disorder.

Social (pragmatic) communication disorder

Social (pragmatic) communication disorder (SCD) is a new diagnosis included under Communication Disorders in the Neurodevelopmental Disorders section of the DSM-5[12]. It is characterized by persistent difficulties with using verbal and nonverbal communication for social purposes, which can interfere with interpersonal relationships, academic achievement and occupational performance, in the absence of restricted and repetitive interests and behaviours (Table ​(Table6).6). Some authors consider that CYP with SCD present with similar but less severe restricted and repetitive interests and behaviours (RRIBs) characteristic of children on the autistic spectrum[41]. SCD is thought to occur more frequently in family members of individuals with autism[42].

Table 6

DSM-5 criteria for social (pragmatic) communication disorder

Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following
Deficits in using communication for social purposes, such as greeting and sharing information, in a manner that is appropriate for social context
Impairment in the ability to change communication to match context or the needs of the listener, such as speaking differently in a classroom than on a playground, talking differently to a child than to an adult, and avoiding use of overly formal language
Difficulties following rules for conversation and storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how to use verbal and nonverbal signals to regulate interaction
Difficulties understanding what is not explicitly stated (e.g., making inferences) and nonliteral or ambiguous meaning of language (e.g., idioms, humor, metaphors, multiple meanings that depend on the context for interpretation)
The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination
The onset of the symptoms is in the early developmental period (but deficits may not become fully manifest until social communication demands exceed limited capacities)
The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains of word structure and grammar, and are not better explained by autism spectrum disorder, intellectual disability (intellectual developmental disorder), global developmental delay, or another mental disorder

The term “pragmatic” has been used previously to describe the communication skills that are needed in normal social intercourse and the rules that govern routine interpersonal interactions, including ability to pay at least some attention to the other person in a conversation, take turns, not interrupting the other speaker unless there is a very good reason, match language and volume to the situation and the listener, etc[43].

Social and pragmatic deficit are known to also occur in diverse clinical populations, including ADHD, William’s syndrome, CD, closed head injury and spina bifida/hydrocephalus[44].

Treatment modalities that have been used for supporting children with SCD are similar to those that have been used for several years in children with ASD (Tables ​(Tables44 and ​and5).5). The first randomized controlled trial of social communication interventions designed primarily for children with SCD was reported in 2012[45].

The Social Communication Intervention Project ( targets development in social understanding and interaction, verbal and non-verbal pragmatic skills and language processing among children with SCD.

Pathological demand avoidance or Newson’s syndrome

Pathological demand avoidance (PDA) or Newson’s Syndrome is increasingly being accepted as part of the autism spectrum. PDA was first used in 2003[46] for describing some CYP with autistic symptoms who showed some challenging behaviours. It is characterized by exceptional levels of demand avoidance requested by others, due to high anxiety levels when the individuals feel that they are losing control.

Avoidance strategies can range from simple refusal, distraction, giving excuses, delaying, arguing, suggesting alternatives and withdrawing into fantasy, to becoming physically incapacitated (with an explanation such as “my legs don’t work”) or selectively mute in many situations. If they feel threatened to comply, they may become verbally or physically aggressive, best described as a “panic attack”, apparently intended to shock[46].

They tend to resort to “socially manipulative” behaviours. The outrageous acts and lack of concern for their behaviour appears to draw parallels with conduct problems (CP) and callous-unemotional traits (CUT), but reward-based techniques, effective with CP and CUT, seem not to work in people with PDA[47]. PDA is currently neither part of the DSM-5[12] nor the ICD-10[13].

Though demand avoidance is a common characteristic of CYP with ASD, it becomes pathological when the levels are disproportionately excessive, and normal daily activities and relationships are negatively impaired. Unlike typically autistic children, people with PDA tend to have much better social communication and interaction skills, and are consequently able to use these abilities to their advantage. They often have highly developed social mimicry and role play, sometimes becoming different characters or personas.

The people with PDA appear to retain a keen awareness of how to “push people’s buttons”, suggesting a level of social insight when compared to CYP with Autism. On the other hand, children with PDA exhibit higher levels of emotional symptoms compared to those with ASD or CD.

They also often experience excessive mood swings and impulsivity. While the prevalence of ASD in boys is more than four times higher compared to that of girls, the risk of developing PDA appears to be the same for both boys and girls[47].

O’Nions et al[48] have recently reported on the development and preliminary validation of the “Extreme Demand Avoidance Questionnaire” (EDA-Q), designed to quantify PDA traits based on parent-reported information, with good sensitivity (0.80) and specificity (0.85). EDA-Q is available online (

Media Contacts:
Scott Sleek – APS
Image Source:
The image is in the public domain.

Original Research: Closed access
“Lipid Profiles at Birth Predict Teacher-Rated Child Emotional and Social Development 5 Years Later”. Erika M. Manczak, Ian H. Gotlib.
Psychological Science doi:10.1177/0956797619885649.


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