Exploring Pathological Demand Avoidance (PDA)

by Diagnoses0 comments

Throughout my career thus far, the term PDA or Pathological Demand Avoidance has crept up on a variety of occasions. More recently I have been working with a young boy and his family who has this diagnosis. I’m sure his family would agree that getting anything done, anything at all, is simply difficult. Although on the increase, there is limited research on this area and how to help and support children with this diagnosis. So, I am always on the look out for new opportunities to learn.

I recently had the opportunity to attend an afternoon workshop for parents and carers who support children with PDA. The workshop was hosted by a volunteer from the PDA Society. The presenter had first hand experience of PDA and was able to share personal experiences and hints and tricks which had worked for their family. 

What is PDA anyway?

PDA in Wales currently comes under the umbrella of Autism. It appears to be a very difficult diagnosis to acquire and can be a postcode lottery on whether a Paediatrician will even recognise it, let alone diagnose it. The central difficulty for people with PDA is their avoidance of, and resistance to the demands they are subjected to and encounter. These can range from the obvious direct instruction to the subtler everyday demands of life. Individuals with PDA experience high levels of anxiety and there is a strong need for them to feel in control in most situations. Any demands or subtle expectation can unsettle a sense of control. In turn, anxiety is heightened, leading to compulsive avoidance. It’s the inability to withstand the avoidance, even with trivial demands, which earns the pathological status (PDA Society 2018).

What does a child with PDA look like?

  • Resist demands obsessively.
  • Adjusts social situations.
  • Typical eye contact.
  • Role play and good imagination.
  • Lack of or reduced social skills.
  • Difficulty with emotional regulation.
  • Difficulties with peer interaction and relationships.
  • Rigid and repetitive interests and behaviours.
  • Children can be brilliant at masking or hiding difficulties for limited periods of time.

Reflective thoughts…

A huge emphasis was placed during the workshop on the importance of trust. When working with children and young people who struggle this way, it is vital to move away from trying to “calm” a situation, rather to build a trusting relationship. A child or young person will go into every situation, every meeting, every social interaction, anxiously trying to avoid any direct or indirect demand placed on them. As a therapist, this can be extremely difficult during a session – when ultimately the aim is to engage and work on skills. It is even more difficult for parents and carers, when children struggle to get through the demands before the day has truly begun e.g. getting up, washed, dressed and ready for school.   

Techniques children with PDA often use: 

  • Distraction.
  • Excuses.
  • Fantasy.
  • Meaningful conversation.
  • Procrastination.
  • Taking control.
  • Fight rather than flight. 

Hints and tips to help….

  • Ross Green suggests taking an alternative approach and creating the correct environment for engagement when they “can’t”. 
  • When anxiety is high, reduce demands as low as possible. 
  • Children and young people with PDA are stuck and require us as the support mechanisms to be flexible on their behalf. 
  • We must change the lens and look at the situation in a different way – from their perspective.
  • Remember that what we see determines our explanations and reactions. Are we observing naughty behaviour or anxiety? 
  • Work on coping strategies when the child or young person is relaxed.
  • Support coping skills by inadvertently working on executive functioning skills/communication/ emotional regulation and cognition. 

Final thoughts and tips…

As well as building trust and confidence, the importance of communication is huge and can determine whether a child or young person will engage in a task.

  • Make demands indirect! 
  • Use 3rd person.
  • De-personalise.
  • Use humour.
  • Use games.
  • Use imagination.
  • Be silly! 


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