PDA and Therapy – Tips for engaging children with the PDA profile of Autism in therapy

July 13, 2019 / / No Comments

I was lucky enough to attend the Asia Pacific Autism Conference in Singapore last month, and had the opportunity to hear from professionals working in the Autism field and Autistic individuals themselves about topics relating to support, interventions, lived experiences and hopes for the future.

I also had the opportunity to present my ideas about supporting children with PDA in therapy, and was encouraged by the interest of the parents, educators and therapists that attended in wanting to find better ways to engage and support the children with PDA in their lives.

Since my blog last year about using trauma informed practice to support children with PDA, and my more recent workshops on the topic, I have heard from many parents and professionals who said that these ideas resonated with them, and that they could see the benefits of working in this way. However, the focus of most information available about PDA has continued to be around managing behaviours at home and school, leaving a big gap in information and knowledge where therapy is concerned.

I am hoping that I can begin to fill that gap.

To that end, I am excited to be writing a new book for Jessica Kingsley Publishers which will be a clinicians guide for working with children with PDA in therapy. However, it is still a work in progress and won’t be released for a while yet.

In the mean time, I wanted to share my tips for supporting and engaging children with PDA in therapy. It is not an exhaustive list, but highlights some of the essential elements I think are necessary to engage in effective therapy.

RELATE: Developing a strong and trusting relationship with a child with PDA takes time, but I believe it is ultimately the key to their support. As a clinician, it is understood that the therapeutic relationship is extremely important in supporting clients to make progress, but for children with PDA it will make the difference between a child being willing to come to sessions and engage on their terms, or refusing to even attend. A therapist must genuinely care for the child and accept them without judgement, or the child will see through their pretence and be threatened by their words and actions, making the therapeutic process ineffective.

PLAY: Play provides a way to allow a child with PDA to take control of their environment and process feelings, thoughts and experiences in a safe and non-threatening way. Whether it is formalised non-directive play therapy, client-led pretend play, or playfully engaging in games and activities in the therapy room, play is by definition an enjoyable experience, and through enjoyment and engagement, children can learn and develop at their own pace.

CREATE: Creative activities such as drawing, painting, colouring, and craft have been found to be therapeutically beneficial for many children and adults, and can be used in therapy settings to support the engagement of children with PDA and also to be used as a tool for relaxation.

PRETEND: Many children with PDA are comfortable in drama and role-play, so incorporating elements of this into therapy sessions, or simply taking the child’s lead and joining them in their role-play, can be an effective way to connect with them and support them to explore concepts and experiences.

REGULATE: Children with PDA are wired to detect threat and as such are often dysregulated. I have found that it is essential to have activities available for children to help them regulate their arousal level and feel safe when they come to therapy. Without the opportunity to regulate, children cannot engage. Sensory activities such as making slime, playing with playdough, water, rice and sand, bouncing on a trampoline or rocking on a swing, can be very effective in supporting a child to feel calm, safe and focussed.

ADAPT: When working with children with PDA, it can be difficult to predict what they might do or say, or how they might react to situations or activities at any given moment. Something they loved to do one session might be anxiety provoking the next, so being prepared for different possibilities, knowing when you need to step back, and being able to take the child’s lead rather than pushing your own agenda are extremely important.

LAUGH: Humour and novelty have been found to be helpful in supporting children with PDA in school, and this certainly also applies to the therapy room. In my experience, children with PDA often have a fantastic sense of humour, and tapping in to their silly side can make therapy more enjoyable and certainly helps to reduce a child’s anxiety in session. Showing that you can laugh at yourself and ‘think outside the box’ also makes clinicians more relatable and activities more interesting, which enhances the therapeutic experience for the child.

COLLABORATE: Children with PDA need to feel that they are an equal partner in any interactions, rather than there being a power imbalance where an adult has authority. It is important to allow the child to take the lead, and for the clinician to cooperate and collaborate with them when engaging in activities, to avoid a power struggle which will increase demand avoidance and anxiety.

UNDERSTAND: The thing that children with PDA need most from the adults in their lives is acceptance and understanding. Understanding that their behaviour is not a deliberate act to be difficult or a choice to be ‘naughty,’ but is a response to feeling anxious and unsafe that requires unconditional love and support. Children need to know we understand them and are on their side so they not only feel accepted by others, but also learn to accept and understand themselves.

I am hopeful that with increased awareness of the PDA profile and a better understanding of the needs of children with PDA in therapy, more clinicians will be in a position to support children to manage their anxiety effectively, and improve the outcomes and quality of life of children with PDA in the community.

Download my Tip Sheet for Therapists (pdf)

Bibliography:

  • Christie, P. et al (2011) Understanding Pathological demand Avoidance Syndrome in Children, JKP Essentials
  • Christie, P. et al (2018) Collaborative Approaches to Learning for Pupils with PDA : Strategies for Education Professionals, Jessica Kingsley Publishers
  • The PDA Society (2016). Pathological Demand Avoidance Syndrome: A Reference Booklet for Health, Education and Social Care Practitioners.
  • https://notesonpda.wordpress.com/a-z-of-demands/
  • https://pdaguidance.wordpress.com/2016/01/28/why-rewards-consequences-dont-work/
  • https://beaconhouse.org.uk/useful-resources/

Supporting Children with PDA using Play and Trauma Informed Practice

November 5, 2018 / / No Comments

It has been almost 12 months since I wrote my first blog about PDA and Play Therapy, and since then my knowledge of PDA and my confidence in the benefits of using Play Therapy with children with PDA has continued to grow. But with that increase in knowledge and confidence has come even more questions. Questions about the source of the anxiety that drives demand avoidance, and about the mechanisms through which play therapy can assist children to cope more effectively with the world around them.

These questions have lead me to form the view that looking at PDA through a trauma-informed lens can help therapists, parents and educators better understand a child’s needs and reactions, and find more effective ways of supporting them.

Now I should clarify that I am not saying that PDA is caused by trauma – I believe the current view that PDA is a profile of behaviour that presents as part of an Autism Spectrum Disorder. However, what I am saying is that the reaction an individual with PDA has to a demand is similar to a trauma response (an extreme emotional reaction to a distressing event, where the stress experienced exceeds the individual’s ability to cope), and by viewing it in this way, we are much more likely to be empathetic and open to adapting our behaviour to support a child’s needs, and have a better understanding of what individuals go through every day.

One of my PDA clients, aged 8, recently likened being at school to being controlled by a remote control, and I think it is a fantastic analogy to consider the experiences of individuals with PDA. Imagine this if you can … someone from work that you don’t know very well has been given a remote control that controls everything you do. You are completely under their control and they can make you do anything they want. How would you feel? Would you be calm and trust that this acquaintance will make sure you hold onto your dignity? Or would you panic at the prospect of being made to do something embarrassing and having no control over it? Most of us would feel the latter – a sense of panic; of being completely out of control; of being helpless and at the mercy of this person they don’t trust. This event may also, in some of us, trigger a trauma response that could go on to impact on our future wellbeing and behaviour.

Now imagine that the person with the remote is you, and the person being controlled is a child with PDA. Further, consider that every demand placed on them is like you controlling them with your remote. Can you see how distressing and how damaging repeatedly experiencing this situation would be?

Given that play therapy in its many forms is an evidence-based intervention for children who have experienced trauma, it makes even more sense to me now that it could be a pathway for healing and developing effective coping skills in children with PDA.

For the children with PDA that I work with, the overwhelming ingredient to positive experiences and therapeutic progress is trust, and that is only gained through developing a strong relationship and having a safe and secure place for them to be. Once that trusting relationship is established, and the child has the opportunity to take control of their life, even just for the hour that they spend with me, they are free to play, make, destroy or talk through their feelings and experiences at their own pace and in their own way. I believe this is where therapeutic progress can be made.

While there has been considerable focus over the last few years on how children with PDA can be supported by parents and educators at home and at school,  there seems to be little information available on how to help individuals with PDA to reduce their anxiety through therapy. It may be that the challenging way that individuals with PDA often present has created a barrier to children receiving support because more traditional ‘talking’ therapies don’t seem to work. But this is where I think Play Therapy fits in.

The more I work with children with PDA and their families, the more confident I feel that play-based, flexible interventions and trauma-informed practice can be utilised to support children with PDA to feel in control and capable of managing any challenges they might face.