A Clinician's Guide to Recognizing Pathological Demand Avoidance

In this compelling episode of The Self Careapist Podcast, Dr. Maylin Griffiths, a clinical psychologist and founder of the Arizona Pediatric Assessment Center, joins Lorain Moorehead, LCSW, to demystify the misunderstood profile of Pathological Demand Avoidance/ Pervasive Drive for Autonomy (PDA).

Dr. Griffiths explains how PDA often hides behind misdiagnoses like ODD or ADHD and share actionable tips for therapists conducting assessments and collaborating with school systems. She emphasizes the role of curiosity in assessments and valuable resources for clinicians and families.

Notes:

• Curiosity drives effective assessment practices.
• Pathological Demand Avoidance (PDA) is a unique profile that requires specific strategies.
• Social strategies can be misinterpreted as manipulative behavior.
• Strengths of PDA kids include creativity and leadership skills.
• Collaboration among professionals is vital for comprehensive assessments.
• Shift from “manipulation” to “equalizing” when thinking about client behavior

Links:

Arizona Pediatric Assessment Center

Navigating PDA in America

PDA North America

Chapters:

00:00 Introduction to Assessment in Psychology
02:57 The Role of Assessments in Therapy
06:05 Understanding ODD and ADHD
08:56 Exploring Pathological Demand Avoidance (PDA)
12:00 Key Components of PDA
14:58 Social Strategies and Coping Mechanisms
18:09 The Impact of Autonomy on Behavior
20:43 Role-Playing and Social Strategies
23:43 Fixation and Its Effects
25:46 Understanding PDA and Autism Profiles
28:23 Navigating Social Dynamics and Self-Identification
30:09 Strategies for Effective Communication
36:13 Managing Demands and Autonomy
39:24 The Role of Sensory Sensitivities
44:15 Strengths and Unique Abilities of PDA Kids
45:46 Resources for Clinicians and Families
47:45 The Importance of Collaborative Assessments

The Self Careapist Therapist Podcast is a biweekly conversation with Lorain Moorehead, LCSW a licensed clinical social worker and owner of Lorain Moorehead Therapy and Consultation in Arizona where we specialize in High Achieving Professionals, EMDR, perinatal mental health, and clinical supervision. We cover therapeutic specialties with mental health professionals from intern to advanced supervisor in mind while dropping gems and aha moments for everyone who loves to learn! If you love learning and want to keep track of some futher learning opportunities, grab your learning map here!

If you liked this episode, feel free to subscribe and leave a review! Your support helps us be a top mental health podcast and resource. See you next week!

Transcript

0:01

Welcome Dr. Griffiths to the Self-Care Apist Podcast. Thanks for having me. I'm excited for us to be able to talk today. Yeah, can you give a little bit of a background on what you do at your office and who you serve? Yeah, sure. So I'm a clinical psychologist by training and in my journey of training found that assessments have always been so incredibly helpful when it comes to the path that we should be on and helping to figure out what's going on from being in residential placements with families to inpatient units to outpatient centers. Assessments has really always been the driver for me on how we seek and help with solutions. And so six years ago, I started up my own assessment practice here in Gilbert and so our practice really focuses on that strength-based whole person assessment process. And we see kids all the way from two to twenty-three and we see a variety of things. I mean, I'd say the most common things that we are looking at are things like ADHD and autism and learning differences, mood, behavior. But really families come to us when they're feeling lost or they're not quite sure what road they're on or should be on or they're having a hard time accessing services. So while it's not diagnostically focused, that sometimes can be the route to get to the end of where we need to be. Yeah, and so with the assessment, sounds like you can kind of put some puzzle pieces together for them, give them an approach and maybe even some direction on where to go next. Yeah, and oftentimes people are maybe just like one degree off and so then we've had the wrong diagnosis or the wrong medication or the wrong type of therapy or not the right school services and we've just kind of gone down this long trail and our assessments really help to look at data and the numbers and also multiple people. So we talk to therapists, teachers, resource specialists, counselors. We want to hear from the med providers, pediatricians, parents, grandparents. So we're kind of like that center person and then we gather all the information around us with the kids and the family kind of being at the center of it and then figuring out how do we get the best support team in place and everybody speaking the same language, doing the same thing, kind of moving in synchrony together and that's really like what the assessment does and is for. that's so interesting to hear how much it sounds like time is spent actually outside of the office or outside of the work with simply the family. Yeah, and we I have found from what I hear from parents when we show up to school meetings, they go very different when we're there. And so I only know my perspective of being there, but what we hear from families is they say, wow, that was that was so different. So we make it a point to go to every 504 and IEP meeting for our families and not as an advocate, but really like an advocate for the data, for the numbers, for the eligibility. So we'll go and share with the team why we think they need these services and what type of services. And we ask a lot of curious. questions like what's the school's plan for this or what's available to the teacher, what kind of resources could we add in, and just kind of really like kick up conversations in those meetings and so even outside of the assessment we're still kind of wanting to make sure we're on the right track at following them to those meetings too. I think that's really helpful to hear that it is that with a lens of curiosity for anybody who might not be currently incorporating school meetings, do you have any ideas on how you can be most helpful or what someone could maybe take away to apply themselves in a future school meeting? Oh yeah, I mean I think the idea is just getting everybody on the same page and so asking how do we best support them. I think there's times where I'll read assessments that will have like 40 amazing ideas that a teacher should and could do and I'll go sit and talk with that teacher and they're like there's absolutely no way that we could put all 40 of those things in place. I mean I have 30 students, I have no supports, yeah in an ideal world this would be great but there's just no way. I think having the idea, I mean that's like parenting too, I can read 900 pages parenting books and go, oh, I'm going to do all those things. But when it really comes down to what I can practically and actually do, it's maybe like 1% of that. And so I think for parents to think about, how do we have those conversations? What would be the most supportive thing in the classroom? How can I help you get to know my kid the best? ah What can I do to show up as a supportive parent for you? Even just those conversations are really great, even outside of like eligibility and services and things like that. that makes sense that it's not necessarily about going in with a bulldozing mentality to a school meeting because practically if they can't do it, it's not gonna get done. So really trying to land on recommendations that can actually practically happen. well it feels the same for me. I don't know how many times I've taken a course or I've read a thing or walked away with a book and been like, these are great, but the chances of me actually applying all of this is not gonna happen. And so what can I really digest and take with me? Yeah, that makes sense. Any other uh ideas on how someone listening right now could implement a more thorough or a more helpful assessment in the office? Yeah, so I think what I like to lean on is the curiosity. When things aren't making sense, it's because it's not making sense and so I really want to have therapists and practitioners think of it like a puzzle when you're trying to jam that last two pieces in. If it's not fitting, it's not fitting. ah So I'm encouraged by our discussion today, but there's a lot of times where I'll see kids come in and they'll have ten different diagnoses and they'll be on four different types of meds and one med does this and the other does that and this diagnosis catches this, but not all of that. then we kind of sit down and everyone's going, yeah, none of this really makes sense. And so I think in those moments for us to say, why is it not making sense? ah I mean, I'd love to talk a little bit too about just some specific behavioral diagnoses when we don't really think about, well, what's the reason for that diagnosis? What's leading to that? ah My absolute like hate of a diagnosis is ODD. We get quite a few kids with ODD and that's it. And so I think when I hear, well, they've been in therapy for two years for ODD, it makes me think, well, maybe we're not asking the right questions or we're not quite understanding this kid's perspective and point of view or we're not putting the right resources in place. I think that's what the assessments do. We just kind of like throw everything in the air and go, all right, let's start new. Yeah, that makes a lot of sense. I'm glad you brought up ODD. Would you say that there is a diagnosis that you're often seeing as more common than ODD in your office? Yeah, so it's the two. It's ODD and ADHD. We have a little bit of a different perspective of ADHD and then I think most six to eight year old boys should have all the criteria for ADHD and when I hear what their environment looks like, I go, of course they're having a hard time with that. Of course that's really tricky and of course that's really hard and so for us it's really piecing together. What will this kid look like at 14 and 16 and 22 and 40? Because the idea of ADHD is that it's lifelong. While it may wax and wean with some but it's not something that is just when you're six to eight and sitting in circle time in a mainstream classroom with 30 other kids is hard. That's hard for most kids. ah So I think we're pretty cautious about over diagnosing ADHD. We really want to see it on the neuropsych measures. I want to see a play out in the office. I want to hear it in multiple environments. I want the kid to have that opportunities to play sports and have a coach and a team. And so I want to like see that pervasively going across domains before we'd be comfortable with an ADHD d And then ODD, so I'm not saying it doesn't exist. I do think that there's a very small percentage of um symptoms that would make sense for ODD to be the diagnosis. It just seems like sometimes that's a I'm not sure and these behaviors are a lot and so we'll call it oppositional behaviors and that's really what it is but I diagnostically I like to lean on the two words of vindictiveness and spitefulness. If we're not hearing those two pieces I would never really think ODD makes the most sense to land on. Yeah. What do you, in your experience, what is more common or what are you diagnosing in place of ODD? Well, we're going backwards, so it could be anything. It could be my anxiety is so high it's driving oppositional behaviors. It could be I am so inattentive and bored in class because I'm really gifted and this whole thing is boring me and therefore my behaviors are being seen as disrespectful because I'm getting up and walking around because I'm bored. It could be learning differences. We have quite a few kids with learning disabilities that are undiscovered until they're 12, 14. We just tested a 14 year old that couldn't read in one of our big public schools and was diagnosed with ODD and ADHD. and they can't read. And so I think it's not that it's, it's missed because it's this, it could be anything. And then what we're seeing is this cluster of oppositional behaviors and we just need to do a better job of going backwards and saying, what's fueling that behavior? Sometimes it's a lot of environmental stress, conflict in the home. ah We've had kids diagnosed with ODD because their grandparents passed away and that was a huge rift in their environmental system, trauma. I mean really anything's on the table. Yeah. Do you see pathological demand avoidance in your practice? Yeah, so I'm excited to talk with you a little bit about what we call PDA or pathological demand avoidance. uh I think if you work with kids or you know kids or you are in a world where there are kids, teachers, uh everyone has seen a kid with PDA. I think we probably just didn't realize that this made more sense to understand it in this way. so PDA is something that came to our office about five years ago from a family who lived about two hours away. and they said. I heard you're curious and I just need someone who's curious. I need someone to really look at this and I'm going to bring you some things that might not make sense, but I just want us to do it together." And I was like, this is my jam. Like this is what I want. I love this. And so we sat down together and I got a chance to meet with her son and I saw him in our office for three hours and was fascinated because it was a kid that we probably would have seen as like a DMDD or like an ODD kind of a kid. Those are all the diagnosis he came with. really shuffling through it, it was making a lot of sense to see it from a different lens and so he started to just get really curious with the research and with what was out there. So PDA has been around for a while. It was introduced in about 1980 so that's what some quick math like 45 years it's not new. Wow that is 45 years ago. We'll leave that part out. about 20, but uh huh. Anyway, so it's big in the UK and it's really big in Australia. So there's a ton of stuff about it. There's a big bank of literature about it. It's just kind of made its way over to the US about five years ago. um I always think we're kind of like adolescents where we can't have anyone tell us it's our idea. We've got to think of it ourselves. And so about five years ago, the US started saying, hey, there's this thing called PDA and... Yeah. m the US might have the same tendencies. yeah, we're niching in on our... And so when we uncovered it, all these other places were like, yeah, we've been seeing this for a while. We've got a lot of stuff on it. So I think it's really like fuel to a fire, like the past five years. And that's about when it got introduced to me. um This mom was incredible. We worked together and then she actually put us on this PDA of North America provider list. So we were the only provider in Arizona that had knowledge of PDA. And I started diving deep into trainings and consultations and the literature and really getting into the like background of PDA, but her putting us on that list, we started to see more of these kids. So we had families coming from California, Nevada, Texas, New Mexico, all over Arizona and while it's one thing to learn about it and read about it, it's another thing to see 50, 60, 70 kids that really all fit this profile and to kind of see the firsthand experience of it. Yeah. uh What are the key components of PDA? What do you see in your office and what did you learn about during your initial deep dive? Yeah. um So pervasive drive for autonomy really is a better word and I want to kind of walk us through. uh pathological demand avoidance was what this was initially tagged as. Remember we were talking about ODD. That's the kind of like it's oppositional behavior. So we think about pathological demand for avoidance. Sure, we're gonna hit those words when we talk about this, but I want to flex your thinking to another way of thinking of it as a pervasive drive for autonomy. So when we go through these, there's four main pillars and then there's two kind of subcategories you'll start to see why actually calling it a pervasive driver autonomy is what what fits this much much better so we try to use that instead we're all about strength based and positive reframing so I think that's our yeah yeah oh yeah and pretty, uh it demonstrates that there's not really anything that can be done about it. And it sounds like em when you're looking at pervasive, like, yeah, we see it a lot and it feels like there's some ability to adapt or make progress. Absolutely, and I think what we think of is, this is just somebody who doesn't like demands. And that's the problem that we'll hear from parents. They just can't handle demands. Everybody has demands. And that's really true. So throughout our human existence, we all have. that we have to comply with and I'll share with you what demands actually means because sometimes it's more than what you actually think about what a demand could be and so PDA is not just somebody who doesn't like demand so that's where I think we switch the word to pervasive drive for autonomy these kids and adults have an extreme extreme need for freedom for autonomy and that need for autonomy overrides everything it overrides uh toileting, hunger, physical, social, it overrides everything you can think of this. I need autonomy and I need freedom of it. So if you think about... ah what a demand could be. So that's the very first kind of pillar that we're looking for, someone who resists the ordinary demands of everyday life. And I think when I first thought of this, I thought, well, a demand is if I say, here, a command really, right? Come here, do this, go there, sure. So that's one type of a demand. But other types of demands that we might not think of are implied demands. So for example, if I say, how are you? I'm... I'm demanding that you interact with me and you say I'm great, how are you? Something as simple as I love you has the demand of I love you too. So it has this like implied interaction of a demand. I can't tell you how many times I messed up with these kids and I said what's your favorite color? Like the demand of being able to answer and you can see it real quick when you do this, you'll see yourself jump into it and go that shouldn't be that hard of a question, but for these kids it's a really hard question. Do you want to sit here? Well, let's sit here like these big kind of open-ended pieces. Sometimes demands are even fun things that they like to do. So a demand can feel like overwhelming if it's something that I love doing. uh What I find sometimes is parents, I don't know if you've ever, for those of us who are parents, if your kid likes a food and you're like yes and you go to Costco and you buy nine million of it, this happens to these kids. They might like a car, a red car Lego and then what they find is that everybody's giving them all these Legos and all these cars. and all these red things and it just becomes this like overwhelming demand to love this thing. Self-imposed demands can be really hard. um A lot of times there can be too much on um what they impose of themselves as the expectation of a demand. So it's all encompassing, but the idea is that they are resisting and avoiding these demands of ordinary everyday life activities. Yeah, when you said you can, you kind of get checked really quick when you place an inadvertent demand on one of these kiddos. What do you see? Is it an expression? Is it a flat out denial or a head shake? I want to jump into the next piece of it because that answers your question. So what we see is social strategies to cope with the stress of these demands and what we hear is manipulation. They're manipulative. They will manipulate the situation. So that's a big keyword. Anytime you hear the word manipulation, I want you to get curious about it because what we are now rephrasing this as is equalizing. So I want you to replace the word manipulating with equalizing. So what these kids will do is will equalize. So what might seem very nonchalant is they will try to take control of the environment. They might refuse their request. They might enter into some type of a negotiation with me. They might make an equal demand of me. So we do cognitive testing and so I might present the blocks and they'll say, now you do one. Or I might say, what's your favorite color? And they'll say, I'm going to use a pencil and you have to use your favorite color. So they'll kind of like put these demands back to me. ah They'll avoid. they'll often, we see a lot of avoidance. We see a lot of task avoidance or delaying the task. I had a lot of kids that would say, we usually do about five minute breaks and they'd be like, I think I'm going to need an hour. I think I'm going to need at least a day or so. I could probably come back tomorrow. So like really kind of, um Delaying the engagement uh doing it their way. So equalizing is another way I'll do it, but I'm gonna do it the way that I want to do it We do a coding task where you have to go in order and it doesn't really make a lot of sense to not just go in another order But I'm actually asking you to do it this way and most of our kids that we are thinking PDA with will say I'm gonna do it my way I'm actually gonna do it the way I want to Or I'll say, have two minutes to do this task. And they'll say, I'm not going to stop at two minutes. I'm going to do it until it's done. And so they'll engage in that way. I'm hearing a real cleverness a real uh skill set in navigating some of that discomfort. Yeah, and it... It feels like it should be helpful or productive, but what we'll see is sometimes the equalizing can be aggressive behaviors. Sometimes it can be physically incapacitating behavior. So we'll hear, can't walk. I can't use the bathroom. We have about 70 % of school refusal in our PDA kids. So most often when we get called in, it's because it's met the threshold of they're not able to even get to school. uh Most of our kids will have, I mean, you over 50%. percent of days are missed and what I'll hear from the kids is I want to go. I do. I want to be in class. I want to be there. I just can't. I can't get there. that feels important too that it's not even, that it can be a demand the kiddo puts on themselves. It's not even necessarily external. It can be something that they know they want to do and simply aren't able to access. And I think that's the frustrating part, especially from the parents too, because it doesn't make sense. You can't tell me you want to go to school and then not go. Don't tell me you, signed you up for this activity and now you won't go, right? And I like to reframe that. It's not that they won't go, it's that they can't go. And they're doing all of these strategies of equalizing to reduce that demand. The third thing that we see, and I think this is always the most fascinating, this is usually my tip off, is there's no... So they have social on the surface, they're socially pretty well connected, which is why we will miss this autism piece of the PDA profile, because they make good eye contact and they engage in social cordial greetings and they do the, you know, the head nodding, the hand gestures, they do all that stuff, but what they struggle with is hierarchy. So there's no sense of hierarchy. at all. We are equal on all levels. I am equal with parents. I am equal with teachers. These are kids that want to be the assistant coach. These are kids, I've even had these kids that say I'm actually gonna ref the game. I'll be in charge of refing the game. Or the coach of the basketball team will be telling the six and seven year old something and the kid will stand up next to the coach and will coach the game. We had one kid, this is incredible, who felt like they had equal ownership in the home as the parents did. It was split three ways, the equity in the home. And so, and you'll hear that a lot. And so I think this is troubling for some parents because they're trying to establish some type of hierarchy, right? They're trying to establish, I'm the parent and you're the kid. But what, this is the teachers too. The teachers will say, this kid will come after class and say, that was a great job teaching the class today. Nice job. They'll give like pointers or they might even stand up in front of the class and start teaching the class themselves. So we'll get a lot of confused teachers going, gosh they're so cute, but they don't quite understand that they're the student and I'm the teacher. So that's a huge like tip off if you hear that too. The other part we'll hear for the communication part is they'll kind of talk to adults like they're adults. And so I'll hear like they're an old soul or they gravitate to the adult set parties or that kind of piece of it. And then the fourth one that we're really looking for, and this is what usually gets called into our office too, is excessive mood swings, zero to 100, extreme, extreme. um Usually it's some type of like breaking things, hitting someone. um These kids have a lot of school suspensions. They have a lot of ah at-home behaviors that are holes in the walls, broken windows, like those pretty aggressive kind of engagement in these mood swings and behavioral upers. And what I hear from parents is, we didn't even see it coming. We didn't even know what triggered it. We had no idea what set them off, which is very different from an ODD or kind of that irritable mood piece of things. Yeah. Those are the four main components that we're looking for with PDA. It sounds like in the fourth one, from your example, you're seeing it across settings too. So sometimes we see that certain settings they're able to comply or go along with the rules as set forth in certain settings. But it sounds like in this, you might be seeing it across different settings and goals. so we are except for when there's these two little side cars that come along with PDA and one of them is role-playing or fantasy playing. So what we'll see in most of our kids while they have adequate social strategies when we dig a little bit deeper what I hear is, oh That's my school schema. That's my school personality. I would never do that in my school personality. I'm right... right now I'm doctor office so-and-so. I'm doctor office May Lynn. Right now I'm podcast interview May Lynn and I would never yell at you as podcast interview and so the one thing sometimes we'll hear is teachers go, I've never seen this and the parents go, it's like Jekyll and Hyde. I asked the school what... do they see this and they say absolutely not and when we piece it down to the kids, what they're really doing is role-playing what they think a student should be like. I'm role-playing how I should be in a doctor's office. I'm role-playing how I think I should be on a basketball team, things like that and so in our assessments what we'll do, they usually come to us as a doctor office guest and so we'll flip that, we'll get on the floor and play with toys or do silly things or... uh make it so it doesn't feel like a doctor's office and you can really see that schema crumble because they're not quite sure how to behave when I'm not in doctor office mode. So it's a big one where if we're not quite seeing a cross setting it's probably because they're using some type of social strategy and that like fantasy role play piece of it. And then I mentioned there's two sidecar so the last one that we usually see is, and I see this more... that others might see, but I see a fixation on one thing, one person, one something. Usually it's a parent or a pet, ah but it could be a peer at school and it's usually like an obsessive fixation and it can be both positive or negative. So it could be like a really loving obsessive like smothering the dog, has to sleep near the dog, like almost like using them to co-regulate and then the other piece of it is really always going after this one sibling, one parent, so I'll ask like who do they usually target and that's always me, it's always little brother, it's always you know the dog or something like that, so that kind of narrowed in fixation is usually a piece of it too. And that fixation can result in positive or negative behaviors. Yeah, so I usually see it like occupying a lot of their thoughts and this is why as I mentioned we get those diagnoses come through. Well here diagnoses like OCD, really obsessive. Well yeah we're checking off a few of those boxes. We're not really having the intrusive thoughts but we are having that kind of obsessive quality about it and then we're seeing that compulsion of targeting that person or needing that person to co-regulate. Yeah. So from your perspective, it's not yet an official diagnosis, right? It's not in the ICD. It's not in the DSM. How do you use it? How do you integrate it for families? in our practice, we really see it as a profile of autism. And I think this is a really important component of it. uh Is it a profile of autism 100 %? I don't know that we have that answer. I think right now we're seeing someone who also meets the criteria for autism and subsequently this profile for PDA. uh there are conversations about could an adult have PDA but not meet the criteria for autism and with our lens in focus we're really seeing those two things as paired together. Is this a like a cousin to autism on this you know something that looks very similar and different maybe with time we'll have that pieced out a little bit better but for right now the kids that we're seeing that meet the profile for PDA are also meeting the criteria for autism so rather than it being a separate diagnosis or an adjunct diagnosis Autism is the diagnosis and then PDA is a profile or a subtype. Interesting. And I think that's really interesting too because sometimes we do get families that say, think this is PDA. And we go, I think, you know, after we really look into it, they have the correct social strategies and they're able to have that social communication piece. And we're not seeing the sensory integration part. We're not seeing any engagement or restricted repetitive behaviors. I think what this is better is maybe an overreaction to anxiety. So anxiety is really driving the bus. And what we're seeing is this avoidance of the anxious situation. So we're kind of capturing it this way versus of a neuro. to kind of. Yeah, that makes sense. I'm thinking of a kiddo right now who identifies as a Fortune 500 CEO. um Do you find that it's helpful to lean in and think through, well, this other challenge that we're having Are those behaviors consistent with your Fortune 500 schema? Or do you find that it is most positive when they break down some of those schemas and try to kind of bring everybody together? Yeah, I mean, think what's our goal? That's always my real big question. What's our goal? um Does this child feel socially supported in a way that helps them to thrive and be successful? And if the answer is yes, then be your Fortune 500 self. Is this kid going into class and creating a lot of social rifts because of this hierarchy and this position they feel they're in? Is that creating a lot of learning difficulties where you're not able to hear the teacher teaching you or the other students trying to interact with you? Are you irritating people? I mean, I that's a great question sometimes we'll ask is like, we always ask these without the kid present, like do they irritate the other kids and we'll hear like yeah the other kids find them really irritating and so that's the piece that we're trying to like nuance out, like becoming more aware of it. Hey when you go on this really long monologue about all of your accolades and don't allow other people to jump in, that creates them to not really want to hang out with you as much, so like getting that kind of perspective. I think for our what do we do about this... we have seen is that helping them know more about themselves, know why this is happening, just more of like the educational piece for parents and having a community to surround themselves with and understand a bit more of the why behind it has been huge for like reduction in the overall stuff that we're trying to quiet down a little bit. Yeah, there's some good research on just that autism diagnosis itself and the reduction in anxiety and depression and even suicidal ideation once they have the diagnosis because things start to make sense for that just internal understanding. Yeah, and there's like there's so many different strategies because we've had the opportunity to see a lot of these kids. We get to try out a lot of different stuff and it's really remarkable thinking about how we used to do assessments five years ago with these kids versus how we do them today. The huge shift, the participation that we get, the insight that we get, the connection that we get is so different than our, it's standardized, this is how we have to do it and you either fit this mold or you don't and we would see these giant, I mean we had kids like running out of the office and destroying things and completely shutting down, really dysregulated, and you don't really get to connect with them or see them when that happens. And what we were doing is just mimicking a lot of things that were happening at home and in classroom, but there's so many subtle shifts that we've learned to make that just completely reduce that pressure on the demands and being able to like show the parents, when I use this phrase or when I said it this way or when I removed that demand did you see how that and you'd like really hands-on showing them and then being able to go into the classrooms and saying you know here's some ways we can set this up really helps them to be successful. could one be direct versus indirect language? So I mean the easiest thing we do is flip the word you to we, so I'll say we need to do this task, we need to sit in this chair, we need to do this. So instead of you do this, you do that, you get this done, I'll say we need to do it. That's such a simple subtle thing. ah there's this other strategy we use where we kind of make it seem like the big boss is making us do this and so I'll say whoever made this test and I'll like get really mad at that person and then we're like a team together, so me and the kid are against the big boss, so I'll say something like... boss just needs us to get this done in two hours and I really hope we can show the boss that we can get it done in two hours. We got to do this, we got to stay focused and I'll say things like we need to take a break or we need to grab a snack, so kind of we're on this team together. We use a lot of declarative language too, so I'll just say there's blocks on the table. We need to get this task done. I wonder how fast we'll get it done and so I'll ask like kind of curious questions. I use a lot of like exaggerated humor too, these kids really respond to that stuff too, so I'll say something like, I mean if it's something silly, I might say like go ahead and write your name down, C-A-T. oh That's not how I spell my name, like I wonder how we spell your name and so then they'll kind of engage in those ways. So there's just a lot or like sometimes we test under the table and sometimes we don't use it exactly as it's supposed to and sometimes I say instead of saying you have two minutes to get this done, I might say let me know when you're finished and then I'm tracking that it's two minutes and I'll kind of notate when to stop it. So we just kind of flip it a little bit. I'm open to negotiations, so I might engage with them a little bit more in negotiations and I might with another kid who doesn't struggle with these pieces. I'm also open to requests, so I might say what's your best idea on how we could get this done? ah I'll do more of like sharing the reasons behind a decision, gosh we're really wanting to give your therapist some feedback on what they can do better in therapy with you or what they can do differently in therapy with you and so that's the reason why I'm asking you these questions, so like rather than them being anxious about what the why behind it is um and then offering... great, I've been meaning to give her some feedback. Yeah. but and I and like inviting them to be a part of the team I think is that hierarchy piece of it. So I'll say we're all on a team together and we need your help to come up with the best decisions and if you think about think about like a traditional family hierarchy where the mom and dad are in charge and the kid just follows directions and does sometimes grandparents have a hard time with this PDA style because they're used to this certain type of like authority hierarchy parenting, they just don't get it that this kid just needs this and they need this, but it just doesn't work with these kids and so if I invite the kid to be a part of the hierarchy with the therapist and the psychiatrist and they're a part of the treatment team, they love that. These are kids that will sit in their IEP meetings and go here's what I need and so we invite them to be a part of that process, giving them some agency and allowing for them to have that autonomy. I've said it before and I'll say it again, but I think the strategies that folks come up with for themselves are beyond, you know, the wisdom that we might think of for them. For sure. And I mean, they're kids, so sometimes they have really incredible ideas that are just absolutely not feasible. And I think that's what's really important because sometimes... you we first started this, the strategy was a no demand environment. Create a no demand environment for this kid and they will thrive and my pushback on that was everybody would thrive in a no demand environment for a period of time, but the world is not no demand. Jobs aren't no demand, schools aren't no demand, you know, there's demands with everyday functioning and so how do we, instead of a no demand, how do we do a low demand environment, especially getting rid of unnecessary demands. So this might be a kid where when they come into the office, I don't say how are you? It's not needed, right? So I might let them come into the office and I might say, oh it's Monday, you know hoping it's a great day today and then I'll sit down and let them engage how they want to. So it's just something simple that I can remove those demands, I just aren't needed or necessary. Yeah. do you ever hear from the client themselves that they can't get themselves to do what they like respond to a text. They can't get themselves to stop their game and go take a bathroom break. Do you ever feel that, yeah, how do they best navigate for themselves, their own demands that they want to do, but feel like they can't get over that threshold once it becomes a demand. Yeah, I think those are the ones that we start with for sure. So we'll hear kids, I mean we've had 12, 13, 14 year olds urinating in their outfits at school because they just can't get to the bathroom or can't stop to this. We've had a lot of ARFID diagnoses because we're having a lot of restricted eating. Can you talk about RFID? Just explain what you mean. Avoidant Restricted Intake Food Disorder. Okay, we got it. But the idea of it is... A lot of the kids we work with just kind of niche into these very specific sensory sensitivities and so it's... they kind of box themselves in to this corner and they go, okay, there's two things I can eat and it has to be this brand and it has to be from this place and they just really get extreme anxiety when we try to introduce other types of foods and so you can imagine the nutritional impact that this might have, the mood impact, the sleep impact, the know, the weight impact that this has and what we see when Arfit is paired with this PDA profile is it's really the amount of demands that comes with trying a new food or unpredictability of foods or the brand being different or how it's going to be served and all of that just feels so overwhelming that we box ourselves into I'm only eating this very predictable thing from this very predictable place. yeah, if it's predictable, there's no demand or I'm making the demand. If it's predictable and I know it, it's something that I can control and be in charge of because even the presentation. I'm reducing the anxiety box into this little tiny box. And so it feels much more digestible, we're talking about food, if the box of that anxiety is more manageable. Yeah. it feels like choices could be an option for it. Are we going to do this first or that first? But then again, it feels like choices could be a demand. Yeah. might say there's an apple on the table and a banana on the table. I wonder which one you'll choose. And then would just walk away. You know, lot of these strategies and the language that you're talking about a lot of clients could benefit from some of this language. honestly parents coming in and giving us feedback is one of the biggest helpful things. So they'll say, we tried explosive childhood. We tried zones of regulation. We tried love and logic. We tried punitive behaviors. We tried consequences. We tried behavior plans at school. Everything's making this worse. And that's usually a big indicator for me that we're not on the right track. If the things that would traditionally work, if it was just a behavioral or an ODD kind of a thing are making it way worse. Think about anxiety. One of our go-tos for anxiety is exposure and response prevention. That's the last thing you would do with a kid with PDA is expose them to the anxiety and prevent them from responding. I that's just gonna drive that lack of autonomy and this drive for needing to have control so much more through the roof. We're gonna overwhelm their system and so what I'll hear sometimes is the things that we thought should have worked or traditionally would have worked, absolutely do not and that's really helpful information. Yeah, yeah, that sensory component is such an important, probably part of the profile also that if senses are being overwhelmed by exposure, then we're not finding that habituation happening. Well, they're accelerating their drive for autonomy by engaging in more egregious behaviors. They're getting louder and getting bigger. um Until you really understand how much this is hard for me, I'm going to show you. And with traditional anxiety, we don't see those types of responses. Yeah. In the way that I'm kind of impressed with the skills that it takes to negotiate do you ever see a sense of like, yeah, that's how I... negotiated that that felt good that I came up with that see that as an everyday part of life. I mean these are kids that parents will say they were like that when they were six months old, it had to be their way. These are kids that have always known it to be this way, so I think that they're meeting their need, they're not necessarily over strategizing or out thinking someone. What I'll hear though from parents is like this giant sense of relief. Finally something's working, we've tried everything and nothing's worked and now finally negotiating works, equalizing works, reducing works and I'll hear from parents out say I'll do anything as long as we can get some relief and so while other people on the outside and even I'll be real honest when I heard about this five years ago I was like what are we doing? We're negotiating with a six-year-old? I don't like... I'm not gonna let a six-year-old tell me what chair I can sit in, that makes no sense and I would hear from these parents that would go I mean they kind of get to tell me when we do things around the house. ah We had a family that um the kid... if the child walked into the home when the lights were off, then the lights stay off. If they walk into the home and the lights are on, then the lights stay on, but if by chance those lights are off at 3 p.m., they stay off and so the family adapted and they would wear a headlamp to cook dinner and to eat dinner and I heard of it and went, what? That's wild. Like, why are we letting this kid dictate the lights on? And the parents both looked at each other and they said, whatever works. we're just doing whatever keeps the peace right now until we can get some regulation and they shared they actually have a lot of fun, they like camping, cooking, they eat dinner like that and the kid loves it, he engages with them, they have wonderful time, family time together, they have no emotional meltdowns and they're working on it. So obviously this isn't a long-term solution, but it's something that they're kind of working on, but I think when you initially hear from these families about the things that they're willing to do to get peace, instead of having this reaction of, my gosh, this kid is like so manipulative or these parents don't know what they're doing or you know, these kind of judgments that we might think of. I really would like for us to get curious and go, well, what would lead a parent to put a headlamp on to cook dinner, right? I mean, peace and what's what's dysregulating that peace so much that this is what we've resorted to and what's driving this kid to be so dysregulated if that rule or justice or you know, or the control and autonomy is not there. Yeah. that creates more productive conversations than just saying, this is an oppositional kid who's being manipulated. uh that makes a lot of sense. um What are some of the strengths that you typically see with this profile? Like, what are the things that these kiddos can seem to do really well? So we usually see these kids when they're pretty dysregulated. So their strengths are not shining and their struggles are really overwhelming their strengths. That's generally when we jump in. What I have heard from families is after we get right resources in place, the right school in place, the right supports in place, right therapy in place, when we can reduce anxiety potentially with medications um or other strategies. m We see a kid who's usually pretty intelligent, pretty bright, pretty creative. We usually see kids who are pretty assertive. ah These are kids that like connections with someone else. Usually they like them to help with self-regulation, but they have those connections of co-regulation with other people. ah These kids usually have some pretty unique interests, which I love connecting them with other kids who have those same interests. ah And these kids are really natural leaders. They've got a lot of experience being on equal playing with adults and so when done correctly they can be pretty assertive and they can be pretty skilled and they can command a room and they can um offer great advice and suggestions. They just need to learn how to do it in a way where it's received well. Yeah, For any clinicians listening, you mentioned that you started your fast track to learning on this five years ago. What are some great resources for people who want to learn more about it or think that they are potentially treating a kid with this profile right now? Yeah, so the PDA of North America Diane Gould is one of the leaders there. I would recommend getting on their listserv. They do weekly trainings from all types of different topics. So we have fatherhood and PDA. We have medications for PDA. We have teaching strategies. So every week there's about two or three different like webinars that you can jump into virtually. They'll also record them for you and send them to you. There's a PDA of North America conference that's coming up. Diane Gould just wrote this book, PDA in North America, which is incredible. We have a few books that look at the different family perspective of PDA. So I would say that there is um enough out there to just get familiar with it and then the big piece of it is just being curious. So I think if you're a curious clinician and you're curious with parents, really letting your mind kind of open to the idea of going down a path that you might not have thought of before and letting the parent really guide you in saying, uh here's what we're seeing, and being open to the idea that this could be some type of a pervasive drive for autonomy. Yeah, I think there are definitely people hearing about this for the first time, which is so exciting. Anything else that is important to mention or that you feel like we should cover about assessments, about doing clinical work with these folks, about PDA? You know, I think our motto or our value system really lies in that every kid is a good kid. And I think if we all have that mindset that within every kid is a lot of goodness and a want to connect with others and to share with others and to be accepted. And the key word we use a lot is the word lonely. Nobody really wants to feel lonely. And so how do we connect them with interests and things? um so I really see the assessment as answering a lot of those questions. get to see this kid as a good kid? How do we get their strengths to shine? How do we interact with them in a way that helps them feel more connected and more supported? And while we talked a lot about PDA, sometimes that could be understanding their learning differences or better treating uh other types of neurodivergence or uh you know things like mood and anxiety. So there's so many different ways I think that the assessments can help to offset those struggles so we can see their strengths and working with people. So I always encourage families, if you're seeking out an assessment, doesn't need to be with us, make sure they're talking to the therapist, make sure they're talking to the teachers, make sure they're talking to the psychiatrist, so that no one's really working in a silo. I think that's the most harmful thing is when we jump into an assessment and I see you know, maybe they're meeting with a therapist once a month and then they're in another place with a psychiatrist and then a pediatrician's prescribing over here and then they're going to this group therapy, but then nobody's And so everybody's kind of doing their own thing. I think one of the benefits of an assessment is really kind of tying that string to everybody to connect us all together. Yeah, that's great feedback. if a clinician wants to make a referral for an assessment or if a family happens to be listening that wants an assessment, anything else that they should be looking for to get a skilled assessment? Yeah, so we like you going to people who are qualified and trained and have experience. There's so many options, so I always recommend parents call lots of places and see who feels like the best fit. I take all of our intake calls, so we schedule 15-minute consult calls with all of our families so that I can talk to them and make sure that we're a good fit for them and that they're a good fit for us. I think that's really important. And then kind of what your, think about like what your three needs are. So for some families, it's expediency. I need this quickly. Some families it's I need someone to go into the schools with me. For some families it's I need to be able to bill insurance, right? uh So there's lots of different kind of what are the three things? I need someone who's really qualified and connect with my kid. So asking those questions and then really kind of checking off those boxes for who the right fit could be. Yeah. Well, thank you so much for your time today. Where can folks find you if they want to read more about your practice? Yeah, so azassessment.com is our website, the Arizona Pediatric Assessment Center. There's so much on our website there. We can schedule those 15-minute consults there, but we also love making those in-person connections. So reaching out through the website is probably the best way and then we can meet in person. All right, that sounds so good. Thank you for your time today. I think this is going to be a really helpful snapshot for people. Thank you, great talking with you today.