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What PDA can look like in clinic

Variability in Engagement One of the most striking features of PDA in a clinical setting is the unpredictability of the child’s presentation. On some days, the child may refuse to attend the appointment altogether. If they do arrive, they might be unable or unwilling to get out of the car or enter the building. Even when physically present in the room, they may:
  • Refuse to leave their parent or carer’s side
  • Be silent, withdrawn, or unable to engage with questions or activities
  • Alternatively, they may be highly articulate and eager to engage, leading wide-ranging conversations or even initiating philosophical discussions
This variability should not be interpreted as manipulative or oppositional behaviour. As Raelene Dundon, educational and developmental psychologist, points out, “What may look like non-compliance is more often a panic-driven attempt to preserve a sense of autonomy and safety.” Recognising this helps to reframe the child’s behaviour in compassionate and constructive terms. Control and Avoidance Dynamics PDAer may attempt to control the therapeutic environment to reduce their anxiety. This can manifest in many ways:
  • Directing the clinician on what they should be doing
  • Interrupting or preventing parents from discussing challenges
  • Refusing to engage unless allowed to choose the location or context-for example, working only under a table or in a specific part of the room
They may also use a variety of avoidance strategies, often framed as plausible excuses: “I’m too tired,” “I am doing this now, but we can do yours next time…” Libby Hill, speech and language therapist, highlights the importance of flexibility in her work with children: “Working with PDA children means needing to leave your ego at the door. Go with the flow, focus on the big picture, and be uber-flexible.”
  • P – Prioritise and Compromise
  • A – Anxiety Management
  • N – Negotiation and Collaboration
  • D – Disguise and Manage Demands
  • A – Adaptation
It’s helpful to think of PANDA not as a checklist, but as a gentle guide – especially helpful if you’re new to PDA support. The real work happens through connection, curiosity and trial and error. “Having a big toolkit means you can be more adaptable in the moment.” You can find our guide to PDA approaches for everyone here. It covers the fundamentals that will help you support PDAers you come across. The rest of the information in this guide is healthcare specific.