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Pda In The Therapy Room A Clinician's Guide To Working With Children With Pathological Demand Avoidance

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Pathological Demand Avoidance (Pda) in Children: a Comprehensive Neurodiversity-Affirming Guide

Understanding Pathological Demand Avoidance

What Is Pda?

Pathological demand avoidance (PDA) is a Neurodevelopmental conditions characterized by extreme Anxiety-driven avoidance of everyday demands and expectations. First identified by Professor Elizabeth Newson in the 1980s, PDA is increasingly recognized as a distinct profile within the autism spectrum. Unlike typical oppositional behavior, PDA involves an automatic stress response triggered by perceived loss of control rather than deliberate defiance.

The core mechanism of PDA is Anxiety about control—not opposition to specific activities. Children with PDA cannot comply when they perceive loss of control, even when strongly motivated to do so. A child who desperately wants to go to the park but cannot put on shoes when told to do so will miss the outing entirely, demonstrating that resistance isn’t about the activity but about maintaining autonomy.

The Nature of Demands in Pda

In PDA, a “demand” extends far beyond direct requests and includes:

  • Direct instructions and suggestions
  • Questions (even “How are you?”)
  • Expectations and praise
  • Indirect demands like hunger or fatigue cues
  • Environmental expectations
  • Self-imposed demands and internal expectations
  • Social obligations and conversational turns

The resistance is pervasive across all life areas, even affecting preferred activities. This distinguishes PDA from typical Demand avoidance—children with PDA will avoid activities they genuinely want to do if someone else initiates them.

Neurological Basis

PDA operates through the same stress response system that produces trauma symptoms. When children with PDA perceive loss of control, their nervous system automatically enters fight, flight, or freeze mode. This response is not within conscious control—it’s a neurologically driven adaptive reaction to perceived threat.

Research suggests PDA brains may be structurally hypersensitive to environmental threat, making individuals more susceptible to toxic stress and adverse childhood experiences. This Neurological difference justifies trauma-informed approaches as essential rather than merely helpful.

Clinical Features of Pda

Core Characteristics

Resistance and Avoidance of Ordinary Demands Children engage in excessive, persistent resistance using negotiation, distraction, social manipulation, claimed incapacity (“my legs don’t work”), or intense arguing. Resistance depends on Anxiety levels—sometimes children can push through demands, other times they cannot. The effort expended is described as “pathological” because it exceeds typical childhood resistance.

Surface Sociability Without Social Depth PDA presents a paradox where children often appear more socially motivated than classically Autistic peers. However, significant gaps exist in:

  • Following multi-person conversations due to processing speed issues
  • Understanding reciprocal friendship and social boundaries
  • Recognizing social hierarchy (treating all people as equals)
  • Reading subtle social cues and Body language
  • Considering how actions impact others’ feelings

Excessive Mood Swings and Impulsivity Due to constant hypervigilance and Anxiety, children struggle with Emotional regulation. Mood changes can appear unpredictable or triggered. The impulsivity stems from automatic threat-reduction responses rather than conscious decision-making. This can manifest as compulsive persistence in prohibited behaviors—the more told not to do something, the more compelled to continue.

Comfortable in Role-Play and Pretending Children with PDA display exceptional creativity and imaginative skills, using role-play to:

  • Avoid demands and control situations
  • Resist direction while participating in Anxiety-provoking activities
  • Explore concepts safely within imagination
  • Mask discomfort by becoming the “perfect student”

Language Development Patterns Many children show early language delay followed by significant catch-up in toddlerhood and preschool years. This differs from typical autism patterns where language gaps may persist.

Obsessive Behavior Often Directed at People Unlike typical Autism’s object or topic focus, PDA obsessions often center on specific people, creating relationship challenges. When focused on a parent, the child insists that parent handle all care activities, exhausting that parent and potentially alienating the other parent.

Associated Characteristics

  • Low self-esteem and self-confidence: By school age, many internalize messages of being “naughty” or “difficult”
  • Threats of violence or obscene language: Often “limbic utterances”—stress responses rather than conscious choices
  • Executive functioning difficulties: Affecting memory, attention, organization, and task initiation
  • Trauma susceptibility: Due to Neurological differences and misunderstanding of behavior

Why Traditional Approaches Fail

The Demand Problem in Traditional Therapy

Traditional Therapy typically involves:

  • Clinician-directed activities and topics
  • Expectation of reflection and discussion
  • Explicit and implicit behavioral expectations
  • Reward and consequence systems

While effective for many children, these approaches escalate Anxiety and trigger Demand avoidance in PDA because:

Automatic Expectation of Compliance Many professionals assume children should automatically respect authority. Children with PDA don’t recognize social hierarchy and won’t comply due to adult status. Authoritative responses trigger increased Anxiety and avoidance.

Clinician-Led Sessions When clinicians direct activities and structure, they remove control from the child, triggering Anxiety. Even incorporating special interests can trigger avoidance if adult-suggested.

Sessions Contain Numerous Demands A standard first session contains multiple explicit and implied demands:

  • “Come in”
  • “Sit down”
  • “How are you?”
  • “What would you like to do?”
  • Waiting room expectations
  • Attendance itself

Reward and Consequence System Issues These systems assume conscious control over behavior, which isn’t true for Anxiety-driven Demand avoidance. Rewards can themselves be perceived as demands and create ongoing performance pressure.

Understanding the Compliance Paradox

The fundamental misunderstanding is viewing PDA as behavioral opposition rather than Neurological Anxiety. Traditional approaches that “work” for oppositional behavior often backfire catastrophically with PDA because they increase the very Anxiety driving the avoidance.

Trauma-informed Approach to Pda

Brain Development and Stress Response

Early brain development follows a bottom-up sequence:

  1. Brainstem (automatic functions, fight/flight/freeze)
  2. Limbic System (attachment, Emotional regulation, relationships)
  3. Cerebral Cortex (higher-order thinking, reasoning)

Brain development depends on experience—stable, nurturing relationships create healthy brain circuitry. When children feel safe, the brain shifts from “survival mode” to connection and higher functioning.

Trauma-Informed Principles

Safety

  • Physically, emotionally, and relationally safe spaces
  • Consider the child’s perception of safety, not just adult perception
  • Adapt environment to prevent rule-breaking rather than creating rules
  • Understand the window of tolerance—smaller for those with trauma or PDA

Trustworthiness

  • Show reliability, consistency, and compassionate responses
  • Keep promises and respect negotiated boundaries
  • Children with PDA have exceptional memories for unkept promises
  • Consistency and calm responses demonstrate stability

Choice

  • Options provide perception of control and reduce vulnerability
  • Limit choices to 2-3 options with time for decision-making
  • Removing demands paradoxically increases engagement
  • Genuine autonomy leads to more openness to suggestions

Collaboration

  • Work from equality where each person has something to offer
  • Involve individuals in decisions affecting them
  • Listen to and consider thoughts and feelings before addressing problems
  • Use problem-solving rather than confrontation when demands cannot be removed

Empowerment

  • Use strengths-based approaches identifying and building on personal resources
  • Support children to take the lead and recognize their words have power
  • Build confidence for self-help and seeking Support when needed
  • Focus on what children can do, not limitations

The “regulate, Relate, Reason” Sequence

Developed by Dr. Bruce Perry, this represents brain development sequencing:

Regulate Support optimal stimulation through:

  • Repetitive, rhythmic activities (walking, dancing, drumming, rocking)
  • Proprioceptive activities (pressure on joints, lifting, climbing)
  • Oral stimulation (straws, bubbles, chewing)
  • Make various regulating activities available for child choice
  • Match child’s energy level then gradually de-escalate

Relate

  • Strong, nurturing relationships are essential for healing and Therapy success
  • Prioritize trusting therapeutic relationships early in Therapy
  • Connection supports brain integration for optimal learning state
  • More important than any specific technique
  • Consistent, compassionate adults who show children they are safe and accepted

Reason

  • Once feeling safe and connected with better brain integration
  • Children can engage higher-order thinking and reasoning
  • Reflect on thoughts, feelings, and experiences
  • Communicate clearly and learn about themselves and others
  • Make conscious decisions about emotional responses and behavior

Beginning Therapy with Pda Children

Intake Information Gathering

Essential Information to Collect:

  • Sensory sensitivities (aversive versus calming input)
  • Special interests and motivations
  • Specific Anxiety triggers and challenging behaviors
  • Signs of stress or agitation (subtle indicators)
  • What calms or regulates the child
  • Child’s strengths and positive attributes
  • Parents’ journey to Diagnosis without judgment

First Session Preparation

Provide Advance Information

  • Explain session format through parents
  • Reduce anticipatory Anxiety by creating inviting picture
  • Emphasize choice and control over activities

Adapt to Child’s Needs

  • Be prepared for any reaction, including refusal to enter
  • Parent may need to remain in sessions initially
  • Sessions may need to be shorter than standard 50-60 minutes
  • Allow time in hallway or waiting area if needed

Give Permission to Observe

  • Resist trained urge to “do” Therapy immediately
  • Be comfortable with silence and exploration time
  • Note what child is drawn to and discusses
  • Don’t force talk or answer demands

Communicate Therapy Role Establish clear Therapy rules focused on safety and trust:

  • You can tell me anything
  • I will never get angry or upset
  • I won’t think problems or concerns are silly
  • You can’t get in trouble in my room
  • Parents can’t tell you off for things you tell me
  • I don’t tell anyone what we talk about unless worried about safety

Set Minimal Boundaries

  • Keep overall limits minimal to avoid overwhelming
  • Focus on safety: “We both need to feel safe”
  • Frame boundaries around safety, not behavior
  • Example: Complete freedom with safety limitations

Practical Therapeutic Strategies

Using Indirect Language

Direct instructions trigger Anxiety and refusal. Instead use:

  • “I wonder…”
  • “I bet you can’t…”
  • “I just noticed…”
  • “I can’t figure out how to do this—do you know?”

Non-verbal indirect approaches:

  • Place activities visibly without drawing attention
  • Shift focus away from child to siblings, parents, or characters
  • Read to teddy bears while child plays elsewhere
  • Use puppets and toys as communication intermediaries

When necessary to set boundaries, deflect responsibility to external authorities (“The law says…”, “My boss requires…”) rather than personal rules.

Play, Creativity, and Movement

Board and Card Games

  • Develop social skills (turn-taking, rule-following, winning/losing)
  • Natural context for problem-solving
  • Low-pressure skill development

Pretend Play and Role-Play

  • Child-led or therapist-led exploration
  • Practice skills safely within imagination
  • Allows concept exploration without demands

Creative Activities

  • Drawing, painting, clay modeling Support regulation
  • Indirect concept reinforcement
  • Expression without verbal pressure

Movement and Sensory Activities

  • Many PDAers need constant movement
  • Pacing while talking, rocking, bouncing
  • Sensory experiences (slime, sand, water, music)
  • Accommodate movement as long as safe

Charades and “Move Like You…” Activities

  • Exceptionally effective for teaching non-verbal communication
  • Leverages PDA strengths in roleplay and drama
  • Non-competitive and individually adaptable
  • Children learn Body language and emotional expression

Managing Non-Engagement

When Children Won’t Engage

  • Explicitly offer choice: “You don’t have to talk if you don’t want to”
  • Acknowledge nervousness as normal
  • Introduce engaging activities and begin yourself
  • After 5-10 minutes, make observations without questions
  • Respect child’s autonomy completely

Supporting Dysregulation

  • Provide co-regulation by matching child’s energy level
  • Gradually bring arousal down for child to follow
  • Make various regulating activities available
  • Offer snacks or drinks if possible
  • Provide safe/quiet space with comfort items

Recognizing Overwhelm

  • Children often can’t explicitly verbalize reaching limits
  • Learn individual behavioral cues
  • Respond immediately to signals without demanding explanation
  • Shift activities without justification to maintain trust

Managing Challenging Behaviors

Aggression and Meltdowns

  • Safety is the priority
  • Remove accessible items and position 1-2 meters away
  • Speak quietly and calmly
  • Reduce Sensory input (dim lights, quiet space)
  • “Ride the wave” until child peaks and comes down
  • Focus on recovery and calming, not consequences
  • Remember: behavior communicates Anxiety, not defiance

Property Damage

  • Stay calm and respond matter-of-factly
  • Remove damaged object without emotional reaction
  • Comment factually about fixing later
  • Reassure child it was a mistake and you’re not upset
  • Avoid valuable/precious items in Therapy room

Swearing and Inappropriate Language

  • Establish clear stance from outset
  • Understand that knowing something is inappropriate can trigger opposite response
  • Allow flexibility while maintaining personal boundaries
  • Set clear personal stance without imposing as rules
  • Prevent power struggles while protecting therapeutic space

Supporting Selective Mutism

  • Never force talking
  • Provide non-verbal response methods (yes/no, physical choices)
  • Use puppets and toys as communication intermediaries
  • Be attuned to non-verbal enjoyment and agitation signs
  • Allow full participation without verbal requirements

Teaching Social Skills Indirectly

Conversation Skills Through Play

Teaching Through Games and Activities

  • Charades for non-verbal communication
  • Role-play scenarios without direct instruction
  • Group games with adult Support
  • Movement-based social activities

Distinguishing Friendly vs. Mean Teasing Teach four Diagnostic questions:

  1. Is the person a friend or family member?
  2. What tone of voice are they using?
  3. What does their Body language indicate?
  4. What are past experiences with this person?

Response Options Practice Based on “The Social Express” program:

  • Accepting and laughing along
  • Making a joke back
  • Standing up for self
  • Walking away

Social Communication Development

  • Speech and language pathologist Support for nuances
  • Emotion vocabulary development
  • Non-verbal communication interpretation
  • Understanding sarcasm, inference, hidden meaning
  • Adapting communication style to different people
  • AAC device Support if needed

Environmental and Session Management

Creating Predictability Without Rigidity

Consistency Benefits

  • Same location, layout, and familiar settings reduce Anxiety
  • Small changes can be introduced occasionally
  • Consistency reduces threat perception and Demand avoidance

Flexibility Requirements

  • Therapist must be extremely responsive to moment-to-moment needs
  • Adjust activities on the fly without resistance
  • Paradoxical combination of predictability and adaptability
  • Same reliable person within same environment, but flexible responses

Introducing Concepts Gently

  • Present ideas briefly (1-2 minutes) with supporting facts
  • Stop immediately and move on without pressure
  • Allow child to process at their own pace
  • Trust the process even if uncertain about absorption
  • Follow child’s interest for further discussion

Strategic Resource Management

  • Provide limited quantities for natural extreme usage
  • Small containers of paint rather than large jars
  • Allow complete usage within reasonable boundaries
  • Match natural tendencies while maintaining practicality

Family Support and Education

Parental Support

Essential Components

  • Listen to Diagnosis journey without judgment
  • Address guilt about past interventions
  • Provide education on PDA neurology
  • Support school advocacy for Accommodations
  • Recognize high stress and potential neurodivergence in parents
  • Encourage enjoyable parent-child time beyond strategies

Parent Education Focus

  • Understanding Anxiety drives Demand avoidance
  • Confidence in Accommodations rather than guilt
  • Recognizing behavior as communication
  • Supporting child’s regulation and control
  • Connecting with Support groups and services

Sibling Support

Validation and Education

  • Acknowledge genuine difficulty of accommodating PDA
  • Educate about PDA and Anxiety to develop empathy
  • Validate complex, conflicting feelings
  • Provide other trusted adults for confiding
  • Develop safety plans when needed
  • Recognize potential trauma from aggression exposure
  • Individual Support when sibling relationships are strained

Systems and Coordination

Multi-System Support

  • Coordinate Support across home, school, and Therapy
  • Advocate for appropriate educational Accommodations
  • Educate professionals who may misunderstand PDA
  • Create consistency across environments while maintaining flexibility

Professional Considerations

Therapeutic Ruptures and Repair

  • Clinician misreading can trigger dysregulation
  • Acknowledge mistakes explicitly and genuinely
  • Repair relationship by returning to child-led practice
  • Children often return unaffected, demonstrating relationship strength
  • Use ruptures as learning opportunities

Limitations and Referrals

When Additional Professional Support Needed

  • Significant aggression risking safety
  • Suicidal or self-harm ideation
  • Severe trauma symptoms unresponsive to Therapy
  • Comorbid conditions requiring psychiatric evaluation
  • Acute crisis situations

Book Scope Limitations

  • Focus on school-age children in Therapy settings
  • Limited coverage of adult transitions, self-Diagnosis
  • Specific educational Accommodations need additional resources
  • Medical and co-occurring condition management beyond scope

Key Therapeutic Insights

Core Understanding Principles

  1. PDA is Anxiety-driven automatic response, not conscious opposition

    • Children “can’t” comply, not “won’t”
    • Behavior is stress response, not defiance
    • Understanding transforms response from discipline to compassion

  2. Traditional Therapy fails because it contains demands

    • Demands trigger core Anxiety mechanism
    • Standard sessions contain multiple explicit and implicit demands
    • Indirect, child-led approaches are essential

  3. Therapeutic relationship is primary intervention

    • More important than any specific technique
    • Strongest predictor of Therapy success
    • Healing damage from misunderstanding and forced compliance

  4. Trauma-informed principles directly address PDA mechanisms

    • Hypervigilance and stress responses parallel trauma
    • Safety, trustworthiness, choice, collaboration, empowerment Support PDA
    • “Regulate, relate, reason” provides sequencing roadmap

Counterintuitive Therapeutic Truths

Removing Demands Increases Engagement

  • Rather than resisting when given control, PDAers become more open
  • Genuine autonomy leads to willingness to try new things
  • Maximum child control with essential safety boundaries

Indirect Approaches Bypass Demand avoidance

  • Direct instruction triggers Anxiety and refusal
  • Indirect learning often more effective than direct
  • Charades, roleplay, and play-based skill development

Parental Accommodation Isn’t “Giving In”

Evidence-Based Resources

Assessment and Diagnostic Tools

Therapeutic Approaches

Skill Development Programs

Support Organizations

Creating Long-Term Success

Building Resilience Through Safety

Resilience development for PDA children focuses on:

  • Establishing genuine safety and predictability
  • Building self-awareness and Self-advocacy skills
  • Developing trusted relationships and Support networks
  • Understanding and accommodating individual needs
  • Celebrating strengths and building confidence

Transition and Future Planning

While the book focuses on childhood Therapy, successful long-term outcomes require:

  • Understanding how PDA manifests in adolescence and adulthood
  • Supporting Self-advocacy and accommodation skills
  • Building independence through low-demand approaches
  • Maintaining therapeutic relationships during transitions
  • Creating supportive environments across life domains

Hope and Possibility

With proper understanding and Support:

  • Children can develop strategies for managing Anxiety
  • Families can create supportive home environments
  • Educational success is possible with appropriate Accommodations
  • Strong relationships and meaningful connections develop
  • Individuals can build lives aligned with their strengths and needs

The Neurodiversity-affirming approach recognizes PDA not as a disorder to be fixed, but as a Neurological difference requiring understanding, accommodation, and Support for individuals to thrive in their own way.