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Can you spot PDA in children and teens whose parents arrive in your therapy practice?

Let’s consider the 5 to 8 age group when demands increase for learning. What might you see if a PDA child is struggling?

Children under 8 can be overtly silly in school in a sociable way. While sweet, they seem vulnerable. They melt down over seemingly small disagreements or slights. They may argue with or defy the teacher. Peers are often confused by them. However, since PDA kids can be highly imaginative and enjoy role play, they can be well liked by their classmates.

When adults attempt to “correct” them they can freeze with confusion. They seem to be unsure why they have attracted attention.

They are sensitive and easily feel embarrassed or ashamed. They may attempt to restore their sense of equilibrium or impose fairness by choosing a child in the class to punish or correct for reasons that make complete sense to them. Their sense of justice is easily inflamed.

Other children recognize their reactivity and may target them.

Children may focus one day but then can’t the next.

Schools look to manage “off days” to encourage work and productivity by establishing rewards and incentives and encourage home school coordination.

Prior to this point, a parent may instinctively recognize that their child needs time at home where they “turn off” and they may have worked to create a soft-landing space and even feel as if they have catered to their child’s “demand” for ease and comfort.

Parents look to create a home life that feels just right for their child as they are aware that anything may otherwise “set them off”. If the family has experienced any stress or changes their child has significant strong reactions to it.

By the 2nd grade, parents feel pressure to help their child comply with school demands like homework and this can lead to a quick uptick in home dysregulation.

These children are now easily recognized as having ADHD, Anxiety and defiance but autism is often overlooked or dismissed.

The child may also now be reactive in school and be disciplined or suspended for aggression. Parents are made to feel as if they have not offered enough structure for their child and feel blamed.

Internalized presentations in children under 8 are those who rarely speak in school who are sensitive and whose feelings are hurt easily. However, they will tend to shut down or cry sensitively rather than react with overt frustration and anger.

They also notice injustice and want fairness but hide this thinking to be self-protective and avoid scrutiny as this would create excruciating self-consciousness.

They avoid overtly when overwhelmed and are very easily identified as anxious.

They may also make a STUDY of the rules to actively comply with demands at school as they can then avoid social missteps, confusion and the anxiety that this will generate in them.

These children may have a rich inner life full of impressions and will spend a great deal of time analyzing their interactions. This inner life can give them poise and mature thinking while also struggling with extreme anxiety. Rather than seeing this mature thinking as the result of meta cognition and meta analysis of social interactions, (which it is), adults may see this child as “holding themselves back” due to extreme anxiety. They will be encouraged to speak up and develop confidence and the child will respond with further withdrawal.

At school the child is masking heavily and at home the parent sees a child that can be highly emotional and can’t cope with simple demands.

While these children crave to connect through their rich inner life, they fear this and appear to hide the best of themselves except for with a best friend or trusted adult.

The child with internalized PDA may not show overt struggles at school from 5 to 8. But this child is VERY aware of their confusion. They hide it and this masking feels instinctual to move through and navigate the demands. They learn “rules” and analyze situations so that they can function but a large part of them is disconnected from the experience.

When situations don’t unfold the way that they expected they are thrown. They become a perfectionist who struggles to tolerate when things veer off plan by even a small extent.

Most of the time, this child seeks to avoid when they no longer can navigate demands. Teachers and parents might “push” the child as well as worry for the child. Parents become very concerned for their child’s mental health.

If a child comes into your office described this way, consider PDA.

But what if the child is over 8? How does Autism continue to go under the radar for some kids well after 8 years of age?

Parents may be doing such a good job instinctively accommodating their child that their child will manage without drawing attention to their pragmatic confusion.

The child in this situation will be understanding their environment cognitively. It’s possible that autism won’t even be suspected well into the high school years or even into young adulthood.

However, this same child may be buckling under the strain at home. Parents may be quite concerned about anxiety, reactivity and isolating. Feelings of shame have gotten so large that they either fall into self-recrimination or defend against it outwardly at family.

They may have depression, ideation and or self-harm.

Many providers they encounter are unaware of how autism looks and feels in an atypical presentation so there are many missed opportunities to address the root cause of distress.

These children may be given multiple diagnoses with mental health support that offers only partial relief and adds further to the family’s confusion about their teen. They are often asked to do things they don’t want to do due to our society’s notions of what healthy choices and educational paths look like.

Young adults can experience a traumatic adolescence due to undiagnosed autism with the PDA profile. They can feel like “lost years”. Children and teens can resist engagement in the next steps of adult life.

Their relationship with parents can become strained and fractured with looming questions related to their future.

These teens have internalized a great deal of self-blame. They may feel themselves to be flawed or broken.

Like most teens they are only exploring what they want and who they are. If they are identified as autistic at this time it will often be because demands have crushed them. These teens withdraw from school, community and family. They may spend a great deal of time in their room and on a screen. Parents become very frightened in these scenarios and teens feel incredibly misunderstood.

If the teen is pushed or confronted directly about their behavior and emotions, they may be verbally or physically aggressive, act erratically and unpredictably and this can precipitate a crisis or hospital stay.

This is true in both an internal and external presentation.

Those who internalize may look almost comatose. They are no longer able to think, emotions are at such a high pitch that their affect erupts very easily, or they look dissociated from their affect and are not connecting to or speaking to anyone. Sleep wake cycles can flip. They will look deeply depressed, and their thinking may not make sense. They prefer to be alone.

Those who externalize may be aggressive, act out, and vocally express themselves saying very similar things such as:

“What’s the purpose of it all”, “Don’t tell me how to think. I need to decide what matters”.

“I don’t understand why I have to know the things that they want to teach”, “This has nothing to do with what I want in my life”.

It feels very existential, and it is. Teens with PDA can sound like young philosophers. Their questions are REAL and incredibly important. But the questions immobilize them in the external world. They are at a standstill due to a backlog of unprocessed feelings about experiences that they masked through and suppressed.

The answers to their questions illustrate their unmet needs in relationships and in their environment. PDA teens need repair with their adults and the adult world.

Clinicians, if you meet a family like this, I hope that this can illustrate how burnout will appear. Not every PDA family has an expression of extreme pathological demand avoidance with the mental health symptoms I describe.

But when PDA has been unrecognized there is more likely to be cumulative distress. An immediate PDA affirming stance will help everyone, parents and children. Offering good information helps families understand how mental health is impacted by unsupported autism.

It is very common for mental health symptoms in undiagnosed autistics to be misidentified as and clustered together as multiple mental health diagnoses. If you suspect PDA, there is no harm in approaching the family with a PDA specific affirming lens.

Best practice for PDA is to be relational and client centered. This helps every client, but it is the ONLY thing that will work for PDA.

Can you recognize the PDA adult who arrives in your practice?

The PDA profile of autism runs in families. If you work with a PDA child, it is highly likely that one or both parents are PDA. It will be important to consider where and how to best support the child.

Because PDA expresses itself “in relationship to” the environment the parent and child may express their traits differently and struggle to fully understand and appreciate one another. This may be true across multiple generations in the same family.

Ultimately, a healthy environment for the PDA child is one where a parent can hold, support and coregulate the feelings of their child. A parent who knows themselves and has actualized enough of these same experiences makes a healthy home for their child.

PDA parents are often frightened parents who have little energy left after meeting their own demands day to day. The therapist can look at the kind of life questions vital to PDA parents to be able to focus on creating good lives for their children.

This can involve reworking of many of the emotions baked into their motivation for parenthood changing their self-concept. This is an incredibly challenging experience for a family. They will often find themselves sitting with the same existential questions their children are.

These parents can feel fragile, vulnerable and exposed. They are actively looking for support and understanding from a therapist.

Those who come to see themselves as having undiagnosed PDA may want to make things easier for their child but are left with all the fears and unprocessed feelings over what they themselves missed and what they have to buffer for their child from relatives or community.

This is often one reason why parents will find themselves in burnout along with their child.

As their child’s struggle unfolded the parent’s memories and feelings of grief and sadness, or reactivity can overwhelm them.

Newly aware self-identified PDA adults are parenting “in extremis” where every place a parent feels vulnerable and unavailable for regulation is felt acutely by the child.

This parent needs your understanding and validation of the complexity of the experience. You will help them understand themselves and their child.