PDA can be incredibly complex and it can be challenging to tease out what is contributing to avoidance behaviour.
The PDA Society is a fantastic source of valuable information regarding PDA. In their guidelines for identifying and assessing PDA they outline that there are many conditions that can co-occur with PDA that can also present in similar ways, however these conditions are distinctly separate and are not the root cause of demand avoidance.
- Oppositional Defiant Disorder (ODD): ODD is often characterised by argumentative behaviour towards people of authority. As a therapist, I am loathed to view children’s behaviour as wilfully defiant and believe there is always more to it. In PDA, what seems like defiance is not a behavioural choice. When faced with demands their nervous system detects threat and triggers a fight, flight, freeze, fawn stress response, their thinking brain has been short circuited. PDAers can experience avoidance across the board, and it can even extend to things that they want to do or enjoy. My son will often say “Mummy I want to, but I’m scared.”
- Anxiety: Often anxiety can present when initially engaging in something new, however it often becomes easier with time and gradual exposure. In PDA it can be quite the opposite. They may engage in new experiences initially, however once the novelty of a task has reduced, and something becomes a routine, or there are increasing expectations around performance, it becomes harder for them to continue to engage. Certainly, in PDA, anxiety or fear of uncertainty might contribute to them becoming overwhelmed, however it is not necessarily the root cause of the avoidance. In our family’s experience, anti-anxiety medication can be beneficial in increasing tolerance levels, however it does not eliminate the demand avoidance, it is still necessary to provide a low-demand environment.
- Trauma: PDAers have sensitive neuroception like that which is often seen in people who have experienced trauma, however trauma is not the root cause of the demand avoidance. PDAers are more likely to experience trauma due to lack of necessary support and accommodations. An example, when my son was attending Daycare he displayed what I thought was separation anxiety (this was before we knew he had PDA). Based on this theory we continued to encourage attending using a graded exposure approach. Unbeknown to us, the very treatment that was in place to assist him was actually causing trauma.
- Intellectual disability. In PDA demand avoidance is not the result of cognitive impairment or an inability to understand instructions.
- Attachment disorders PDA is not the result of insecure attachment. Even within the most attuned parent-child relationship, your child can still have PDA. I would argue that parents of PDAers often become expertly attuned to their kids.
- ADHD: PDAers share similarities with ADHD in wanting to be self-directed in their learning and driven to seek out novelty/dopamine inducing experiences. However, their demand avoidance is not stemming from difficulties with executive functioning e.g. organisation, working memory, planning and sequencing. For example, our PDAer is capable of dressing himself, however he is unable to consistently complete this due to demand avoidance.
- Dyspraxia is a neurological condition that impacts the ability to plan, coordinate and carry out physical movements. PDAers are often inconsistent in their ability to carry out physical tasks such as brushing their teeth, bathing or writing; however, this is not due to any physical or motor planning difficulties. An example of this, our PDAer attended an unstructured gym program as a toddler. He was able to complete all elements of program, however he would freeze whenever the coach was watching him and placing a demand on his performance.
Throughout my career I have always stood by the foundations of assuming competence, and in the scenarios where a child is unable to participate, assuming there is always a good reason, it is not just a behavioural choice. When working with children who presents with PDA, my sense is that a low-demand, collaborative and flexible approach should always be put in place first, before exploring what other barriers might also be impacting upon participation.
