PDA in the Therapy Room

1. Understanding PDA: A Unique Autism Profile Driven by Anxiety

For individuals with PDA, not being in control of their actions or their environment triggers an automatic stress response, just like the response that might be triggered in a person who has experienced trauma.

Anxiety-driven demand avoidance. Pathological Demand Avoidance (PDA) is a profile within the autism spectrum characterized by extreme anxiety and a need for control. This anxiety leads to avoidance of everyday demands and difficulties with emotional regulation.

Key features of PDA:

• Resists and avoids ordinary demands of life
• Appears sociable on the surface but lacks depth of understanding
• Excessive mood swings and impulsivity
• Comfortable in role-play and pretending
• Obsessive behavior, often directed at other people

Diagnostic considerations. While not yet recognized in the DSM-5 or ICD-11, PDA is increasingly acknowledged as a distinct autism profile. Diagnosis typically involves comprehensive assessment by a multidisciplinary team, considering developmental history, behavior across settings, and differential diagnoses.

2. The Impact of Trauma on PDA and the Need for Trauma-Informed Approaches

When a child experiences repeated adverse events or is exposed to continuous or prolonged toxic stress, their brain is exposed to increased levels of stress hormones such as cortisol and adrenaline. This results in the brain being in a heightened state all the time, constantly scanning the environment for threats and being easily triggered into survival mode.

Trauma and PDA similarities. The hypervigilance and high anxiety levels in PDA mirror those seen in individuals who have experienced trauma. Both conditions involve an automatic stress response to perceived threats in the environment.

Trauma-informed principles for PDA:

• Safety: Create a physically and emotionally safe environment
• Trustworthiness: Be consistent and reliable in interactions
• Choice: Provide options to give a sense of control
• Collaboration: Work together as equals
• Empowerment: Use a strengths-based approach

Regulate, relate, reason. This sequence, developed by Dr. Bruce Perry, emphasizes the need for safety and connection before learning can occur. In therapy, focus on helping the child regulate their nervous system, build a relationship, and then engage in higher-level thinking and problem-solving.

3. Building Trust and Safety in Therapy with PDA Children

Developing a strong and trusting relationship with a child with PDA takes time, but I believe it is ultimately the key to their support and successful intervention.

Prioritize relationship-building. A strong therapeutic relationship is crucial for effective intervention with PDA children. Take time to learn about the child's interests, share moments of connection, and be consistent in your responses.

Creating a safe therapy environment:

• Allow the child to take the lead and be in control
• Provide regulating activities and a safe space for calming
• Make the environment predictable and consistent
• Recognize and respond to signs of overwhelm
• Remove or reduce demands whenever possible

Establish clear boundaries. Set minimal, non-negotiable rules focused on safety (e.g., no hurting oneself or others, no intentional property damage). Be flexible with other aspects of the session to avoid power struggles and maintain the child's sense of control.

4. Adapting Therapy Techniques for PDA: Indirect and Play-Based Approaches

Working with a child with PDA is likely to be a long-term investment of time and energy, so patience is absolutely key to being successful. These children need the opportunity to move forward at their own pace, within the context of a safe and trusting relationship, towards their desired goal.

Indirect communication. Use indirect language and approaches to introduce information and engage the child. This might include wondering aloud, pretending to be confused, or shifting focus away from the child onto toys or characters.

Play-based techniques:

• Use board games and card games to practice social skills
• Incorporate pretend play to explore concepts and process experiences
• Engage in creative activities like drawing, painting, and crafts
• Find opportunities for humor and silliness
• Use role-play and drama to practice skills and express emotions

Flexibility is key. Be prepared to change direction quickly based on the child's needs and responses. Allow for movement and sensory experiences throughout the session to support regulation.

5. Managing Demand Avoidance and Reducing Anxiety in Therapy Sessions

As the main characteristic of PDA is demand avoidance due to an anxiety-driven need to be in control to feel safe, it makes sense that one of the important factors in therapy for PDAers is reducing or removing demands.

Minimize direct demands. Allow the child to take the lead in sessions and avoid giving direct instructions or making suggestions whenever possible. When demands are unavoidable, use collaborative problem-solving to find mutually agreeable solutions.

Strategies for reducing anxiety:

• Use indirect language (e.g., "I wonder if...")
• Shift focus away from the child onto toys or characters
• Deflect responsibility to a higher power or imaginary character when necessary
• Provide choices to give a sense of control
• Use the child's strengths and interests as a foundation

Be patient and understanding. Recognize that progress may be slow and unconventional. Focus on building a healing relationship and celebrate small victories rather than pushing for rapid change.

6. Supporting Emotional Regulation and Social Skills Development in PDA

Understanding anxiety and other big emotions (e.g. anger, frustration), it is important to have an understanding of the way the brain and body respond to threats and challenges in their environment.

Teach emotional awareness. Help children recognize and understand their emotions through activities like making faces, identifying feelings in the body, and exploring the physical sensations associated with different emotions.

Emotional regulation strategies:

• Introduce concepts like "red thoughts and green thoughts"
• Practice deep breathing and progressive muscle relaxation
• Use the "size of the problem" framework to put challenges in perspective
• Engage in activities that build interoception skills

Social skills development. Focus on indirect approaches to teach social communication, friendship skills, and perspective-taking. Use videos, books, and role-play to explore social concepts without putting pressure on the child.

7. Empowering Families and Siblings of Children with PDA

While the focus of individual therapy might primarily be working with the child to support them with their challenges, no child should be viewed in isolation from the family and community in which they live.

Support for parents. Provide a safe space for parents to share their journey, manage guilt and shame, and learn effective parenting strategies for PDA. Educate parents about the neurology of PDA and advocate for appropriate accommodations in educational settings.

Sibling support:

• Acknowledge the challenges of being a sibling to a PDAer
• Educate siblings about PDA and anxiety
• Validate complex feelings and provide a safe space to express them
• Teach strategies for staying safe during meltdowns or aggressive episodes
• Recognize potential trauma and refer for individual support when needed

Encourage family connection. Help parents find ways to spend enjoyable time with their PDA child, focusing on shared interests and positive experiences rather than constant management of behavior.

8. Troubleshooting Challenges in PDA Therapy Sessions

Even with all the knowledge and skill in the world, there will be times when a clinician does not read a child's behaviour accurately and ends up pushing them past their tolerance level, triggering a threat response.

Common challenges and solutions:

• Child won't engage: Provide space, offer choices, and engage indirectly
• Child is dysregulated: Focus on co-regulation and provide calming activities
• Child becomes aggressive: Prioritize safety, remain calm, and wait for the storm to pass
• Child damages property: Stay calm, remove the item, and reassure the child
• Child uses shocking language: Remain neutral and don't take it personally
• Child can't or won't talk: Offer non-verbal communication options and use puppets or toys

Learn from mistakes. If you push a child too far, acknowledge your error, apologize, and take steps to repair the relationship. Use these experiences as opportunities for growth and better understanding of the child's needs.

Last updated: August 8, 2024