Creating a Family: Talk about Adoption, Foster & Kinship Care

What is Pathological Demand Avoidance and How Do I Parent This Child?

• Creating a Family • Season 20 • Episode 10

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Are you familiar with pathological demand avoidance? Do you need helpful strategies to raise a child with the challenging behaviors that characterize PDA? Listen in to this conversation with Dr. Cynthia Martin, a clinical psychologist, the former Senior Director of the Autism Center at the Child Mind Institute, and founder of CM Psychology in Manhattan, NY.

In this episode, we discuss:

  • What is Pathological Demand Avoidance?
  • What makes PDA different from typical defiance or resistance?
  • Is PDA considered an official diagnosis, or is it more of a way to describe a cluster of behaviors that we’re seeing in some kids?
  • What do we know about the underlying causes?
  • How does PDA relate to other conditions like autism or ADHD? What are the overlaps with trauma, prenatal substance exposure??
  • What are the types of behaviors parents or caregivers might see?
  • How can a caregiver tell the difference between a child who can’t comply and one who won’t comply?
  • Where do parents start when considering if their child has a PDA profile?
  • What observations or examples should parents share to help a clinician understand their child’s challenges?
  • What kinds of strategies are effective for parenting a child with PDA traits?
  • How can parents reframe their approach so that daily demands — like getting dressed, brushing teeth, or doing homework — don’t turn into constant battles?
  • What types of therapies or interventions tend to be most helpful? 
  • What do you say to caregivers who are feeling worn down and ineffective? Where do they start?
  • How can a parent or caregiver set their child up for success even if they do have this PDA profile?
  • What words of hope or encouragement would you offer to parents and caregivers just starting to investigate?

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Please pardon any errors, this is an automated transcript.

Welcome to Creating a Family, talk about adoption, foster care, and kinship care.
Today, we're exploring a topic that may be new to many of our listeners. It's
called pathological demand avoidance, often also called PDA. It's a behavior profile
that can be especially confusing and challenging for parents and caregivers, raising
those children who have experienced trauma, loss, or prenatal exposure. Hello,
my name is Tracy Whitney, and I am your host for today's conversation. I am also
the content director for CreatingAFamily .org, and I'm thrilled to be able to
introduce you today to Dr. Cynthia Martin, who is here to help us understand
pathological demand avoidance, where it comes from, and how to support our children
who face this diagnosis. Dr. Martin is a clinical psychologist trained in pediatric
neuropsychology. She is an expert in autism and neurodevelopmental disorders. She
currently runs a private practice in New York City, and prior to opening that
practice, she was a clinical professor at Cornell and Harvard Medical Schools and the
Senior Director of the Autism Center at the Child Mind Institute. She has published
in peer -reviewed journals, presented nationally and internationally, and co -authored
book chapters, her work and expertise have been featured in popular media outlets
like Time Magazine, CBS Mornings, ABC Now, and Fox 5. She's also an adoptive mother
of two. Welcome, Dr. Martin. Hi, good morning, Tracy. Thank you so much for having
me and for the warm welcome. We're so glad that you came and spent some time with
us this morning to talk about this. We actually received a letter from one of our
listeners, and they were asking us,
diagnosis. So let's talk a little bit about what it is and how it's different from
just maybe typical defiance or resistance that children just show developmentally
across the stages. Wonderful. So pathological demand avoidance are what people commonly
refer to as PDA. It's a behavioral profile. So it's a cluster of patterns of
behavior that we observe in a broad array of individuals, many of whom have
underlying neurodevelopmental conditions. And what we see is that individuals have
really high reactivity and resistance to everyday demands.
So something that for a lot of people feels kind of neutral or maybe even feels a
little bit boring or mundane or not the most fun thing, to a person who has a
profile of PDA, that demand might feel incredibly overwhelming or very threatening.
It can often trigger or elicit a strong anxiety response that can lead to a lot of
avoidance or shutting down. And on the outside, it can look like willful defiance or
disobedience, but it's really due to having an extreme need for autonomy or control
over one's environment.
anxiety or a mood dysregulation disorder. Okay.
So kind of a mixed bag of origin that has these,
you keep saying cluster of behaviors. So is there like a profile of behaviors that
fit this cluster combination? Yeah. So when we,
so when I say behavior, I mean what we observe. So a behavior is something that is
observable. We see it on the outside. So it's something that we can measure, we can
time, we can count. Like my behavior right now is I'm here speaking with you
answering questions. I'm moving my hands around as I talk. Those are all things that
are observable to the person on the on the outside. So that's just kind of a way
to think about when we say behavior, that's what we mean, things that we can
observe on the outside. Behavior, though, is often just the tip of the iceberg.
who when you want them to do things that are just part of ordinary daily life.
So let's get up and get dressed. Come eat breakfast now. Oh,
the bus is here. We need to get out the door. Put your shoes on. When they're in
class, the teacher says, okay, everybody, eyes up here. Take out your morning work.
Let's start our independent work. It's time to pack up now and go to gym.
These just kinds of everyday, daily types of expectations and requests of people to
a child who is described as having this more PDA profile, they may have a really
hard time going along with those expectations and those demands. So that could range
from starting in the morning, you know, when the parent is saying, Okay, come on.
Get up. We got to go. It's almost time. It's almost time to go to school. Let's
go get breakfast. That child might say no. They might just not respond and just
keep doing what it is that they want to do or what they're more interested or
their attention is more focused on at that time. Or you might get a really extreme
outburst. The child might cry, scream, yell, say a lot of unkind words.
So you could have a whole range of those things. And that could happen really at
any time. It could be things that happen at home when the parent is giving these
everyday types of instructions and demands and expectations, and it could happen
equally at home and at school, or you might see it more in one environment than in
another. So depending on the relationship that the child has with the individual
who's making the demands or giving the directives and also kind of their level of
being able to cope with those demands in that particular environment might mitigate
how flexible or cooperative or tolerant they are of those demands and expectations.
So you might see, that's just all to say you might see more tantrums or meltdowns
because of the expectations in certain environments and in certain interactions,
you might see more of those in some of those situations than in others. Okay.
And how does it relate? You mentioned neurological conditions like autism and ADHD.
How does it relate to those types of neurological differences. Yeah.
So when I have parents calling in saying, you know, I think my child has a has a
PDA profile. I've been reading about pathological demand avoidance. I think this
really applies to my child. When I get those calls and then I go through a pretty
comprehensive evaluation for the child, I often find that the child does meet
clinical criteria for a neurodevelopmental disorder. Oftentimes, autism.
And typically the type of autism that I see in individuals whose parents are calling
in describing these PDA profiles is typically a form of autism where the child has
very strong and high language skills. And they often typically have really high
cognitive or IQ skills. So they have some things that just come so easy for them.
And these could be things that for the majority of people actually don't come very
easy for them. And so for these children, it comes super easy. But then the things
that are the routine daily expectations, the social expectations, the executive
functioning expectations, those things do not come as easy for them.
So I often see that there's that asynchronous development and that real unevenness or
mismatch in terms of what their strengths are and how those strengths fit in with
their weaknesses. And that comes from a neurodevelopmental place because it's just how
their brain is wired. They are processing information in their day -to day life
differently from the majority of kids around them. And that is, what I see is it's
often coming from autism, but it might also be autism and ADHD together because kids
who have autism have much higher rates of also having ADHD. And ADHD can really
affect how you can navigate your day -to -day, how you can focus your attention and
be able to delay gratification and also be able to inhibit and manage any impulses
that come in. So I see the kids who have that combination of autism and ADHD,
along with having pretty high IQ. They often have some co -occurring anxiety that
when we put all those things together are often what's under that surface of parents
saying like my child this PDA just makes a lot of sense for my child right that's
a lot for a kid to manage yeah all that internal state stuff hey listeners sorry
to interrupt but i just wanted to let you know that we want to hear from you how
did you find this podcast where did you listen to it what brings you back if you
are a repeat listener. We want to know what has your adoption, foster, or kinship
story been like so far. We love learning about you and what makes you tick. So
please use the link in your podcast player or the link in the YouTube show notes
to share something about yourself with us today. Let's go back to our interview with
Dr. Martin. So for our listeners who are parenting children who have experienced
early trauma or prenatal substance exposure or other challenges at the beginning of
life, how do those layers impact or mimic PDA or create the conditions for PDA?
Yeah, that's a really good connection there. So especially when we think about early
trauma, so early trauma is going to impact brain development. And it's going to
impact how a child, the associations that a child makes with various factors in
their environment. If a child has been in a situation where they have felt very
unsafe and they need to really shift into survival mode, their brains are going to
remember that. So even when they are out of that situation and now they're actually
in a stable, safe environment, their brain is still wired to be really anxious and
sensitive to any possible trauma cues or signals. And so when there are certain
trauma cues or trauma signals, their little brains are just going to shift into an
anxious, protective state. And one of the primary hallmarks of anxiety is avoidance.
So when something triggers anxiety in a child, especially if that anxiety is coming
from a place of trauma, you're going to see a lot of avoidance. And sometimes that
avoidance can also have some behavioral signs where, you know, maybe there's some of
the obvious ones where they're withdrawing and they don't want to go near that thing
that's making them feel anxious. But you can also see pretty extreme dysregulation
and really heightened behavioral responses, like yelling, screaming,
kicking, crying, pulling their own hair, pulling somebody else's hair, doing things
that could be destructive towards themselves or to other people because they have
become so dysregulated in face of that trigger for anxiety that's related to that
trauma history, that can involve a lot of avoidance that can look a lot like what
we see in children whose parents are describing these PDA profiles. So you described
avoidance. That's fairly common. And you described reactions that may be seen out of
proportion to the ask or to the scenario that's going on what are some other
behaviors that might be kind of little clues that we should be paying attention to
yeah so some other clues can be when a child has the ability to do something but
when it is imposed on them they have a really hard time doing it so to give a
kind of a simple day -to -day answer. You know, we need to put our shoes on to
leave the house, right? Putting your shoes on is a skill. You've got to be able to
know where your shoes are. You have to go and get them. You need to put them on
the right feet. You need to close them in some way. So there's a whole series of
steps of skills to be able to complete the task of putting your shoes on. So a
child might be very capable of doing those things independently, but might really
struggle to actually do it independently. And if you notice, well, wow, you know,
they struggle the most when I say, hey, come on, it's time to put your shoes on.
By making that statement to the child and telling them, hey, come on, it's time to
put your shoes on, you get a really big reaction. That just seems really
disproportionate with the ask. And it might even be the child's going, they need to
put their shoes on to go outside and go somewhere.
to maybe the rush or the hurry of getting their shoes on and someone who is having
this big reaction and they truly, in that moment of dysregulation,
can't. Right. Great question. Great question. So a lot of it comes down to really
observing patterns across time. So seeing, okay, is this, is this a one off,
like, is this just happening in the mornings when, oh, you know, I mean, as
parents, we know, like, the mornings are so, are so hard, says the parent who put
her kid on the bus yesterday with the kid's backpack on my back, which is not
helpful. So, yep, did that yesterday morning. So mornings are,
mornings are, can be really tough and hectic. So if you look at the situation and
you notice, like, you know what, on the weekends, when me as the parent, I'm calm,
I'm relaxed, there's a ton of time. My child has no problem doing this when I say,
oh, this is what we have to do now. And it's really just concentrated on these
like rushed, hairy moments when there's lots of things going on. And I'm,
as the parent, may be putting a lot of extra pressure on the situation. Well,
that's going to be pretty typical and appropriate. And also, given the age and the
developmental level of the child, you want to also think about that. Like a really
young child, a toddler, my goodness, those toddlers, they really want autonomy. So
God forbid that you ask them to do something, it really needs to be their idea.
Because they're learning, and it's developmentally appropriate, that they're learning,
like, hey, I have agency. I can say what I want to do and when I want to do it.
So if you notice, like, all right, this is.
in a lot of different things. And it's happening pretty regularly. And I'm seeing it
happening in different types of situations. It's happening at home. It's happening at
school. It's happening across multiple parents or caregivers. It's also happening with
teachers. And then the question you always have to ask yourself is, is it a
problem? And if it is a problem because, and you want to really think about that,
you know, is it a problem? And it is going to be a problem if it's getting in
your child's way of something. If you're noticing like, wow, they're really upset a
lot of the time or they're missing things because of this or they're missing out on
opportunities. Well, so now that you're seeing a pattern over time, it's happening in
multiple situations, it's present more days than it's not, and it is actually
creating a problem for them in some way. Well, then that is more indicative of
there's probably something clinical going on that's going to need a little bit more
specialized investigation and some more help and support to get that child in a more
comfortable place to be able to manage the demands of everyday life.
And you mentioned And that sometimes if it's just a developmentally appropriate need
for independence, one of the things that's tricky in our community of adopted foster
and kinship kids is that because of their early life trauma or other challenges that
they experienced before joining our family, they are often developing unevenly.
Absolutely. And so I think your point about observing is really well taken.
that we shouldn't be ignoring what our gut says. So this is really impacting our
child's quality of life and you know based on experience with other children or what
you know about typical child development. If you know that these clusters of
behaviors are negatively impacting their quality of life or your family's quality of
life because the whole family can be impacted by these things, then it's time to go
ahead and start thinking about, you know, what's going on clinically. Absolutely.
Yeah, absolutely. And I think within that, another thing that as parents that we
have to be really mindful of, especially when we're parenting children who have
complex histories that may have had adoption histories, disruption in care, trauma,
foster, we really need to look very much into our own patterns of behavior.
us. And we have to really be aware of those things because we have to be so
present for our child in a way where we are aware of what some of our natural
knee -jerk instincts are going to be and be able to think to ourselves, is this the
best thing to do in this moment? Or do I need to pause that for myself a little
bit? Yeah. Yeah, that brings up also the additional point of self -care.
for our kids, we can't do that if we're bone dry in our well,
you know? Absolutely. So knowing yourself, and I love your point about knowing your
triggers, knowing your family history, knowing how you were parented. We have great
resources at creating a family to help parents and caregivers dig into that if
they're interested, but then also coming to the table, fueled and refreshed and ready
to handle what today has for you and your child. 100%. And being patient with
ourselves in that because, you know, most of us, I think we now are, there are
cohorts of parents now who are not from the 1900s, like most of us. But we were,
a lot of us were, we were parented differently. There were, there was a different
understanding of children and neurodevelopment and mental health when many of us were
being raised. And so we do want to think about what we know now and how we can
navigate parenting a little bit differently than how it was navigated for us. And I
mentioned that as being an important factor because for a child who struggles with
meeting demands and expectations of everyday life and experiences a lot of
dysregulation due to those demands. We are not going to be able to help them by
meeting inflexibility and rigidity with inflexibility and rigidity. So two inflexibles
doesn't make a flexible. Right. So as the parent and as the adults,
we're the ones who are going to have to take on an immense amount of patience and
flexibility and understanding of our child in order to really be able to help them.
And that takes a lot of making sure our needs are met with self -care like you
were describing. Our founding director, Don Davenport, used to tell me when I was
learning about adoptive parenting, set your expectations low and then be willing to
lower them again. And holding those expectations loosely is such a key to navigating
the steps ahead when you're looking at something like PDA or any other impact that
our kids have to face when they're learning how to navigate the world after adoption
or foster care. Yeah.
So because PDA is not a formal diagnosis, it can be really hard for parents to
know where to start and who to contact and what to do. How do you think parents
could kind of start the process of having their child evaluated and working with a
professional who understands this? Right. Yeah. So I would recommend connecting with a
professional who has a background and expertise in neurodevelopmental disorders and
internalizing and externalizing conditions that commonly co -occur with neurodevelopmental
disorders. So not somebody who kind of only knows autism and ADHD, but they
understand autism and ADHD, and they also understand anxiety, depression,
behavior disorders, mood, mood dysregulation, because it's really when a lot of those
conditions come together. And so That could be a, it could be a psychologist,
a child psychologist who specializes in pediatric psychology or neurodevelopment.
It could also be a developmental pediatrician or child psychologist. There are some
child neurologists who are focused in, who've done additional training specifically in
neurodevelopmental disorders. It could also be of starting with more frontline
community -based providers. Like, it could be mental health professionals at your
child's school, or it could be a local counseling agency. And so talking with
reaching out and saying, you know, hey, these are some things I'm seeing with my
child. I noticed that completing everyday activities that they're actually really
capable of is very, very challenging for them. And I've read a lot about PDA,
and I think they might have some PDA profile present. I would like to get some
more evaluation for their neurodevelopment to see if there's any identifiable clinical
diagnosis that might be driving some of this behavior. Okay. So when a parent or
caregiver walks into that first evaluation meeting, what should they share with the
evaluator to help them understand kind of the full picture of what a parent might
be or a caregiver might be feeling very concerned about. Yeah,
well, so I think they want to share what they observe. So as somebody who does, I
do many evaluations with children from all over the world, actually. And so I always
start with listening. I want to hear, I want to do a lot of listening, a lot of
asking open -ended questions and really hearing about what do they see in their child
day to day? Where are the pain points or the trigger points? Where are the hard
moments? And I want to hear a lot about that and give the parent a lot of time
to really think about it, talk about it, and describe it. So you're not necessarily
running down a checklist with a parent or a caregiver. You're starting a conversation
and kind of letting them unfold what they see and experience in everyday life.
Absolutely. And then I'm asking questions within that because as parents are
describing that, then I start picking up on all right. I'm hearing some things in
the realm of neurodevelopmental differences. Ooh, I'm hearing. It sounds like this
child probably has super high IQ. Oh, I'm, I'm hearing some features of anxiety now.
Ooh, I'm hearing some patterns of behavior that seem like now they've been reinforced
within this family system or within this school system. Ooh, I'm hearing some lack
of attunement between some of what this child's temperament and needs might be and
how the environment is kind of geared towards approaching them. And so I want to
hear all those pieces. Then there's also going to be some checklists involved. And
So that's going to be a little bit more through. We have a lot of norm -based
broadband scales, narrow -band scales. Broadband scales are going to look broadly at
any common child, neurodevelopmental or mental health condition. Narrow -band scales
look more specifically at specific disorders. And so I'm going to also administer
some of those because that gives me some norm -reference data to look at the
presence or absence of certain types of symptom profiles for this child as compared
to children who are of a similar age and similar gender, biological sex at birth,
norm referenced samples. And so I'm going to do some of that. I'm also then going
to be doing some direct testing as well as observation with the child because
that'll help me to understand, okay, are there some identifiable neurodevelopmental
orders present. I'm also going to want to know about the child's cognitive skills.
So how are they thinking and processing? What are their reasoning skills like? What's
their processing speed like? That helps me understand their cognitive functioning and
how they are using their brain to just navigate day -to -day situations,
whether at home or at school. And what we often see in a lot of kids is there
can be a lot of unevenness where they may have some things that come really
naturally, other things that can be a bit more effortful for them. Some things might
be below age level. And if there are some of those, we want to capture and
understand where those are. And so I'm going to be administering a lot of testing
with the child and having the parents complete measures as well. And then I'm going
to want some information about the child and other environment. So that's going to
often come from teachers or if the child has been working with a therapist or a
group of outpatient treatment providers, I'm going to want to also get some
information from them, either from them also completing some norm reference scales or
providing some report. I'll usually do collateral calls to talk with families or,
sorry, talk with providers, other providers or teachers over the phone to again here,
what are they seeing? Where are the tough parts for this child? And So where are
the child's strengths? What are the types of scenarios or situations where this child
is really functioning at an optimal level and where are the areas where they are
more dysregulated and really not functioning well for themselves?
Wow, super thorough. And it sounds to me that you're saying as soon as the kids
are able to report their own behaviors or their own feelings and thoughts, you
include them in the process as well. Yeah, absolutely. That's great. Because their
perspective, they are, you know, kids are wonderfully the experts of themselves.
And so I always tell when I meet with a child, I tell them, oh, I'm a little bit
like a teacher, like I'm a little bit of like a teacher mixed with a scientist. I
want to learn about them. And they are the expert of themselves.
and I'm going to be
might be reporting. Absolutely. Yeah. So is there kind of an age range that is most
common for families that are landing in your office? Typically, when kids are landed
in my office, when I'm getting calls from parents saying, you know, I read about
PDA. I think my child might show some, a lot of demand avoidance. I would like to
get them evaluated. Typically, they are as young as kindergarten first grade and then
up into the early, early to mid teenage years. So it tends to be around big
transition points where they often what I hear from parents is they kind of always
knew their child was a little bit different than the majority. They needed things in
a little bit more of a different way than the majority of kids, but it was
manageable. They were able to accommodate. They were able to have teachers who really
could kind of individualize and understand what that child needed. But then they got
into an environment where that accommodation and understanding was now no longer
happening. And maybe that wasn't happening because now all of a sudden there's a big
jump up in what's expected of kids of that age.
So there might be a big jump -in developmental expectations. It might also be a
period of time where now the academic coursework has increased in complexity a lot.
So a child who kind of knew their ABCs from the time they were two,
they flew through preschool and kindergarten really easily, but then they got to
first grade. And now, ooh, now there's a lot more work and a lot less play.
And you're starting to now,
or social functioning or independence in their day -to -day life. Well,
that's a great segue into the part of the conversation that every parent who's been
listening thus far wants to know what will help our kids and help us help our
kids. So let's talk a little bit about some of the strategies that you find to be
most effective for parenting a child who has these pathological demand avoidance
traits. Great. So this part, I'll talk about it kind of generally, but I want to,
as I, I want to give a caveat to that to keep in mind that there's really never
going to be a one -size -fits -all for any child. And kids who have demand avoidance,
you do have to get a bit to the root of why is that demand avoidance occurring?
And then what are some of the situational factors that are exacerbating. So you do
need to, you do need to really understand it at an in -depth level for your
individual child. But I'll talk broadly about some areas, some trends that I
typically see as being helpful. Okay. So one, an analogy that I like to use to
start with is to think about your child as a flower. Okay. And so when you think
about flowers, let's say you are, you're growing dandelions and you're growing
orchids. Now, if you take one environment and you try to grow both your dandelion
and your orchid in the same environment, one is going to thrive and one is going
to not thrive. And it's going to be the orchid that can't, that can't handle that
environment. Now, in that scenario, you don't look at the orchid and say, you
defiant thing. You are, you're not doing what you're supposed to do. This is so
wrong.
that as humans, we are not quite as simple. We're not going to be as happy with
just like having our environment set up and being watered from time to time. But so
much more dynamic. However, I think it's a nice framework and baseline to think
about to start. So because the first thing, when we're seeing like, oh, we are
really going head to head with our child in something and we're trying to get them
to do something, whether it be brush their teeth or clean up their room or do
their homework, and we are getting huge meltdowns when we ask that. And we think
what we're asking is very reasonable. So when you find yourself in that situation,
the first thing you want to do is take a step back, look at the environment. You
want to think about, are there certain things that are exacerbating my child's lack
of apparent motivation or meltdown response to these.
that's quite addictive for a young child's brain like YouTube, are you trying to go
immediately from YouTube with no warning to you need to brush your teeth and go to
bed? So that is recipe to not go well for a lot of kids. And kids who have that
PDA profile, you are very unlikely to be successful in that situation.
So you want to look at all those factors. In general, we want to try to give
children a high degree of control over their own decisions and the course of actions
that need to take place. Now, when I say a high degree of control, though, I don't
mean completely loosen up. It doesn't mean it's a free -for -all and whatever the
child wants to do is what they get to do when they want to do it. That's not
healthy either. But we need to give them a high degree of perceived control. And so
some of the ways that you can do that is you can shift your language around from
having more of a directive form of language to using more declarative statements. You
can also give your child a cue that something they don't love to do is going to
be coming up soon. So going back to that example, it's downtime. They're enjoying
some screen time. you want to kind of set up the screen time already in advance so
that they know that at some point it is going to end. So maybe your regular
routine is in the evenings. You know, we regularly after dinner and before bed for
this 30 or 60 minute period of time, we have screen time. Like as a family, that's
what we do. So when that's coming up, you want to let your child know, oh, I see
that you are, you know, you're watching, you know, insert whatever it is, you're
watching a YouTuber who's describing Minecraft, you know, all those influencers who
walk through the Minecraft things. Maybe you say like, oh, I see, oh, you're really
interested in that Minecraft. You're watching the Minecraft person right now.
I notice that screen time is going to be over in about five minutes And then just
pause, right? Okay. So you're just bringing it in to your child's attention that
like, ooh, they're interested in something. You notice they're interested in that. And
you're also noticing that the time is starting to get short and it's going to be
time to wrap that up soon. So that helps bring the upcoming transition into the
child's conscious attention. Okay. Without you directly saying in five minutes that's
over. Because that you might just get a reaction. When you use more of a
declarative statement, it gives your child the chance to say, oh, oh, you know,
they're right. Okay, this is happening. I've got to do this thing next. So it gives
them the chance and opportunity to be the ones who rise to that and say, oh,
well, yeah, I don't, I don't actually, I don't want to, I don't want to go brush
my teeth. I want to finish doing this. And then if, and that's likely. I mean, I
think very few children are going to be like, oh, wonderful. Yeah, you know what,
let me just turn this off three minutes early and go brush my teeth. But it gives
them the opportunity to say something like, oh, no, I need to watch more of this.
I'm not done with this. And then that as the parent gives you the opportunity to
help them with the flexibility and some negotiation and compromise, where you can say
something like you can validate, you know, oh, I know this is so important to you.
I know you love that. You love this YouTuber. This is so interesting. I wonder how
much time is left on that video. And you can always say, you know, I wonder. You
know, like you're wondering yourself. You're not saying to them like, well, how much
time is left? Right. I wonder how much time is left on that video. And then that
gives them the opportunity to maybe look and say like, oh, Oh, actually, there's
only three minutes left. And so great. Now they paid attention that. Oh, there's
only three minutes left. Oh, well, nice. Well, there's only three minutes left and
you have five minutes left. Or if they say, you know, oh, well, there's seven
minutes left. And then maybe you say, oh, okay, well, you have five minutes left.
But this video is only, there's only seven. So do you think would it make sense to
finish this? Like get to the seven minutes. I can be flexible and do two more
minutes of screen time before we go on to brushing our teeth. You know, it helps
have this dialogue where then your child could say like, oh, yeah. And then they're
also feeling comfortable and safe and understood that you know what their priorities
are. You're not trying to abruptly get them to finish what they want to do, to go
and do something that nobody particularly likes to do. And so that helps, helps them
make those connections around being able to downregulate from one thing and transition
into the next thing now at the same time if your child says oh there's three hours
left of this um well now that might be something where we're not going to be able
to wrap that up in you know something reasonable within five minutes so then it
gives you an opportunity to offer something else there So, oh, wow,
okay, there's two hours, three hours, whatever it is. Oh, that's a lot of time. So
there's a lot of time left on this video you want to watch. And we have five
minutes until we're going to have to start thinking about going on to the next
thing. And then you just kind of pause. So you want to make some of these
statements and then pause because that gives the child an opportunity to think about
a solution. And then within that, you know, if they are coming up with something
great and but most kids aren't going to, aren't going to come up with something
that you're likely going to be immediately in agreement with. So, but they might
come up with something or then you can suggest something like, oh, I wonder, so
this is really important to you. I wonder what would happen if we find a part
where it where it could be paused. Is there a point where it could be paused and
then kind of wait and ask? And so you're having, and so this is why for the
parent, you have to really have your self -care really well stocked because this
takes a lot of patience to be able to ask these questions and pause and negotiate
with the child. Then once you start getting the point where it needs to be wrapped
up, you can say, again, giving them control over things, do you want to pause it
or should I posit? Should we take it with us into the bathroom or should we leave
it here? So you're giving these options two choices at a time to kind of guide and
give the child perceived control around that transition. And we always remind parents,
make sure the two or three choices that you're offering are choices you can live
with. Absolutely. If you offer choices that are unreasonable or untenable for you,
and that's the choice your child chooses, you're stuck with it. You offer that to
them. You want to be a person of integrity that sticks to their word because you're
modeling this for your child. So don't suggest way out crazy things that cannot be
implemented. Absolutely. I guarantee you that's going to be the one that your child
chooses. 100%. And then another thing to that is you want to make sure that you
don't phrase something in the form of a question where if the child says no,
you don't actually, you're not actually going to honor the no. So something like, do
you want to brush your teeth right now, if you ask that question and they say no.
Right. Where do you go from here? Exactly. So if no is not an acceptable response,
don't frame it as a question. Right. Right. Do you want to brush your teeth right
now or in five minutes? Excellent. Yes. Or with the great flavored toothpaste or the
bubble gum flavored
Absolutely. Yes, exactly. Oh, so it sounds a lot like you're advising parents to
reframe their approach and come in gentle and soft that's not going to trigger any
of that self -protection that would rise up. You know, we talk a lot in trauma
circles about giving voice and choice. And it sounds to me like this is just kind
of an extended version of that with a lot more parental patients and flexibility
built in for that individual child. Absolutely. And with that,
what you're then teaching the child over time is you're teaching the child that the
people around them understand what is important to them. They see that and they want
to help them to be able to have time to do the things that are important to them.
And they simultaneously know that there's some things in life that we just have to
do. And we know those things are hard for them. And we're going to help them to
be able to do that. And we're going to do that in a way that doesn't overly
trigger and overwhelm them from the perspective of the anxiety. And we know that for
a lot of these kids, the idea of cognitive flexibility, so of like coming up with
a of what could be a reasonable compromise or how could they through this.
It doesn't come as naturally. So that's where providing that declarative language and
sometimes even really formally teaching them in a clinical setting how being flexible
actually gives them more power and what being flexible means and in concrete ways
how to learn how to be flexible, That can be really powerful for a child, as well
as giving them some psychoeducation around what actually happens in the brain when
they experience anxiety and helping them understand what some of their anxiety
triggers are. So that brings us to the conversation about the therapies and
interventions that we parents and caregivers can be seeking out for our children in
addition to the strategies and frameworks that we're working on at home. So what
therapies do you see to be most successful when a child is in a classroom?
tools and we have a lot of good evidence -based therapies, but how those specifically
apply to the individual child is not going to be cookie cutter. So you do want to
make sure that you're working with a provider that has a really solid background and
evidence -based intervention, as well as a really just good understanding of
therapeutic processes and temperament, child development, dynamics and relationships,
you know, you really need to have all of that in order to really effectively
individualize and tailor an intervention approach to a specific child and family.
So, but within all of that, some general things that I find to be helpful is I
really like the unstuck and on target program that was developed by a group at
Children's National. It's So wonderful. It teaches kids really broken down skills
around how to be flexible and why being flexible is valuable.
And to be able to think about flexibility as a tool and a resource that they can
use in their day -to -day life. Because some kids are just not going to be as
naturally flexible. And that's okay. We're not trying to change who people are, but
we're trying to have them understand what their own natural tendencies are and how
they can navigate the world in the most effective way for themselves. And so giving
kids these tools where they learn what it means to be flexible and how to be
flexible can be really valuable. And that also has, there's a parent coaching
component where you can also give parents tools and strategies around how to help
their child be more flexible. So I like
have to find some mutuality around how to navigate that together. It often can't be
all one way or all another. I find those approaches really helpful. And then a lot
of cognitive behavioral therapy for understanding of anxiety and the cycle of anxiety
and how we can have a lot of automatic negative thoughts, as automatic negative
thoughts that even if we might have some evidence to say, well, maybe some of them
are true, they might not be very helpful to us in that moment. So understanding how
to help our thoughts and purposefully use thoughts that can be a little bit more
helpful in that situation, I think has a lot of value. And then within cognitive
behavioral therapy, you can, when we're thinking about cognitive behavioral therapy for
anxiety, you can learn more about from the physiological perspective what's happening
in your brain and in your body when you feel and experience anxiety, and how can
you help counteract some of that by using some mindfulness or deep breathing types
of strategies to reverse some of that anxiety response? And now I know every single
kid says deep breathing doesn't work, blah, blah, blah. You know, every, that is
always where kids start. But it is true that if you do truly learn how to use
some of these strategies in an effective way, it is absolutely not going to make
you go from experiencing anxiety to having no anxiety in those situations, but it's
going to help to not make the anxiety worse in those situations. And so that's
often when we're using these strategies is what we're trying to do in those moments
is help a child recognize what's happening in their body, do something when it's
starting to bubble up at a low level, to stop it from getting to a higher level.
And so I find that the combination
and teach those skills in a way where they can be more successful. And all of what
you just said just reminded me of a strategy for parents to try at home that would
be narrating our own experiences. I'm feeling really anxious right now.
I just got home and I have four things to do that are all pressing on me and
feel really big and all need to be tackled. I need to think about how I can just
do one at a time. Absolutely. And kind of narrating, because that's going to mimic
what they're hearing in their therapeutic interventions, noticing what's going on
inside of ourselves, narrating it out loud for our kids, and then going about
modeling how to implement all of that. I find, you know,
when our kids are developing language, depending on how young they've joined our
family, when they're first developing their language, it's a very natural response.
with them, gives them the language. And I find in, you know, my parenting
experiences and in the families that I get to work with, I find that when we are
giving language to children where language wasn't there before, whether it's emotional
language, learning how to identify their feelings, or understanding what's going on
inside of them, it's so empowering and equipping for the kids that they start to
want more of it because they like how it feels when they know that they can say,
this is what's going on inside of me, mom. How can you help me with it?
Absolutely. And that is one of, I think another reason why it's so valuable for
parents to say and narrate some of that out loud is because otherwise the child
doesn't know. They're observing behavior. And especially if if a child comes from a,
has a complex history, they are likely going to be viewing what they see in a way
that might not be truly reflective of what is actually going on for that parent or
in that situation. And they're actually, they're often going to be looking at
situations in a way and interpreting them in a way that might be geared towards
making sure they remain safe and there aren't things that are going to hurt them or
trigger them. And so when the parent is just saying things out loud, like, oh, you
know, I have four things on my mind. Well, now that helps the child understand, oh,
when I saw mom's face like that or I saw that body language, I thought I did
something wrong and they were upset with it. Right. Right. So it takes out of that
and it just, it normalizes so much and helps teach so much to that child who's
really paying attention and is hypervigilant to their environment. Yeah.
Listeners, I have one more interruption. I'd like to tell you about the Jockey Being
Family Library of 15 free online courses. And they're available with a certificate of
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Let's go back to our interview with Dr. Martin.
So talking a little bit about the caregivers and the parents, this again is a long
patient's required kind of process. What's something that you can offer to parents
and caregivers to help them feel like they can wrap their hands around something and
get effective at maybe just one thing? Yeah. Well, I would think if I had to pick
just one, if your child has, if you are noticing that your child has a strong
pattern of behaviors that seems to be suggestive of a PDA profile. I think one of
the best things you could do is take a look at what are all these demands being
placed on them during the day. And what are the ones that are really like the must
-dos? I mean, they're really crucial and need to be done because they are something
that is very important and critical for that child's life functioning,
and then what are all the things that actually really don't matter? And really ask
yourself that. And then focus your efforts on the things that really are important
and just drop out some of the things that are a little bit less important. And
then within that, prioritize your relationship with your child and helping them not
have repeated experiences of really high insurmountable degrees of anxiety.
So observing what's going on in your home and what's going on with that child and
then streamlining where you can so that you're focusing on, you're majoring on the
majors, not majoring on the minors. How can we set ourselves up for success in this
process while still maintaining some level of order in our homes.
Yeah. Well, I think you want to keep in mind that for at least like most of the
kids who I see, when parents are describing PDA profiles, most often the kids do
have neurodevelopmental disorders. So many times autism, sometimes autism and ADHD, and
Those are lifelong conditions for most kids. Now, that's, so what that means is it
is going to be, they are going to be navigating life in a way that is different
from the majority of people around them. So you want to be thinking about this as
a marathon, not a sprint. Don't expect to have change overnight.
Really be thinking about how can you set up rhythms and patterns in your family in
your child's day -to -day life that is going to help them over time be able to
navigate the stressors of life in a way that is most optimal for them.
So for parents who are just beginning to suspect that this conversation about
pathological demand avoidance might apply to them and their child, what words of hope
or encouragement would you offer them as they kind of get started on all of these
observations and self -care and things like that? Yeah,
well, I would say that because a lot of what we see in kids whose parents are
describing a PDA profile, because there are identifiable conditions associated with
most of those profiles, whether it be autism, ADHD, anxiety, mood dysregulation.
We know a lot about those clinical conditions now. And we know a lot about the
heterogeneity and the variability and the complexity and the transdiagnostic
presentation. And we are so much better able as a field right now to be able to
help kids with those profiles. So I would say the hope for parents is get connected
with a professional who can do a deep dive in the evaluation because we know a lot
more now about those identifiable neurodevelopmental conditions than we did even 10
years ago. And there are many more tools that schools and providers can use to help
kids be able to navigate life and be able to learn skills and strategies that don't
come to them as naturally. And I think one of the themes that I've heard throughout
this entire conversation that I would offer as hope and encouragement to parents is
that when you are educating yourself and educating your child, you are creating the
opportunity for this child to be a great self -advocate and very self -aware so that
they can go on to find what makes them thrive and what makes them shine.
And to me, that's what pretty much every parent wants is how can I help my child
thrive? Absolutely. Well, Dr. Martin, thank you so much for joining us today and for
sharing your experiences and your expertise. Thank you for helping us understand how
ADHD and autism and trauma and all of those things can play into and go into the
whole complex cluster of behaviors. I think this conversation is going to be very
helpful for many of the families in our community who listen and are trying to
navigate challenging paths ahead of them with their kids. Listeners, we're going to
put some links in the show notes to help you out if you think this might apply to
your family. so you can start to do your own deep dive and look through those
resources. So thanks so much everybody for listening and thank you again, Dr. Martin.
Thank you so much for having me.