PDA w/ Dr. Hilda Ho

Hilda: 00:00:00

There aren't a lot of good quality research about PDA right now. That makes sense given the stage of research. We have a pda. It is very beginner stage.

This is what we usually expect with emerging kind of theories where there is not a lot of good quality data. So that's kind of where we're at with PDA right now. So, yes, it does make it tricky because it is not a DSM 5.

I think we're coming up to a DSM 6 soon, but it's not in the diagnostic manual right now.

Brittany: 00:00:27

Hey, everyone, I'm Brittany, speech language pathologist.

Shawna: 00:00:30

And I'm Shawna, behavior analysis.

Brittany: 00:00:32

And we're your hosts at Neurodiversally Speaking.

Shawna: 00:00:34

This is a podcast where we bridge the gap between research and practice, exploring autism and neurodiversity through the lens of speech and behavior.

Brittany: 00:00:41

Whether you're a parent or a professional, we'll give you practical tips to bring into your home or your next therapy session.

Shawna: 00:00:47

Let's get started.

Narrator: 00:00:48

Welcome to the Neurodiversally Speaking podcast with Brittany Clark and Shawna Fleming from lmno, brought to you by the Sensory Supply.

While we aim to make Neurodiversally Speaking suitable for all audiences, mature subject matter can sometimes be discussed, suitable only for those over the age of 18.

If you're under the age of 18, please talk to your parent or guardian before listening to our show or listen together with them to stay up to date on new episode releases and show updates. Connect with us on Instagram @NeurodiversallySpeaking.

You can also send us listener questions to address on the show at hello@NeurodiversallySpeaking.com Neurodiversally Speaking starts now.

Brittany: 00:01:37

Welcome back to Neurodiversally Speaking. We're your hosts, Brittany and Sha2na, and we're clinicians who really care about evidence. Informed, but also neuroafforming.

Sorry, Neuro affirming conversations. Today we're talking about a topic that actually comes up a lot in assessments, parent conversations, and certainly in social media.

We're talking about PDA or pathological demand avoidance. Like I said, families are sometimes asking us about IT professionals. I find myself as a speech pathologist trying to understand. Understand it.

And what we'll sort of get our sense from today is that the research is still evolving, right?

Shawna: 00:02:13

And even the podcast, some of our listeners, this is, these are the questions they have about is this pathological demand avoidance or kids who maybe have that sort of profile.

And so to help us unpack where the concept comes from, what we actually know how we can support kids who are experiencing this with compassion and clarity. We're joined by Dr. Hilda Ho today. She is a registered psychologist with the College of Health and care professionals of B.C.

who specialize in autism assessments for children age two to 16. But her journey within this work is really meaningful.

She became a psychologist specifically to work in the field of autism spectrum disorder, starting her career in Hong Kong. Her research background focused on evidence based education and her dissertation actually explored countries that weren't using ABA and why.

So we're so grateful to have you here today. Dr. Hilda Ho, thanks for joining us.

Hilda: 00:03:07

Thank you for having me. I'm so excited.

Shawna: 00:03:09

Fantastic. Why don't you tell us a little bit more about your story and sort of how you've come to be a psychologist.

Hilda: 00:03:16

Yeah, that's a great long story. I think to summarize, I initially didn't think I wanted to become a psychologist. So I started back in undergrad. I want to go to law school.

So I did a joint degree in political science and psychology. And, and it was only up until my last year that I was like, hey, you know, I'm not really into the law piece, but I am really into the psych piece.

So I then got involved into research and things like that. And that brought me back to Hong Kong where I did additional graduate training. So I want to learn more about research, I want to learn more policy.

So I did my degree in master's in public health in Hong Kong. Cool. And then through that, my first job out of grad school was to become was an autism intervention.

And I think that really set the rest of my career because my first work was as a behavioral interventionist. And there I learned so many things and I was really excited to kind of continue to work in this field. So since then, that was, you know, almost.

That was over 15 years ago. So since then I've come back to Canada. I did my grad school in Canada and I did my postdoc in California.

And then now I'm in Vancouver as a psychologist working in this field.

Shawna: 00:04:32

Wow, thank you so much for sharing. Now I want to take a step back to when you were in Hong Kong, I think, and you did your dissertation.

Tell me more about your inspiration for the dissertation and then more about it.

Hilda: 00:04:44

Okay, that sounds great. So actually in Hong Kong when I first started, I worked as a research manager.

So my first study wasn't part of my dissertation was prior to grad school. And how that came about was I. It was through working as a behavioral interventionist.

So just to give you guys a little bit of context, I think back then, this was over 15 years ago. So working in Aba in Hong Kong, this is still relatively new.

So I was working there and this was a really, this was a really great school because at that time it was very, it was kind of a state of the art. These were kids who. We had an ABA school, but it was also attached to a mainstream international school.

So what this meant was that we would be running programs with our kids upstairs, working on different types of skills, from toilet training to transitions, to working with social skills.

But then for some of these kids, if they wanted to, we could also bring them to the mainstream school and include them part of that mainstream environment, which is excellent because we were all part of the same school in working in this type of school. The other thing to also note is that these were the families that are part of the school. They were mainly expats.

So a lot of them had financial resources and were able to speak English. And that's how they were able to access a school like this, even for these parents.

I guess we all work with families and we work with them very closely.

So I started talking with a lot of these families and they were telling me it was really hard for them to get access still, despite having a lot of resources. So that was what made me wonder, okay, well, if this was this hard for families with these resources, what is it like for other families?

Yeah, and that's kind of what brought me into the research in Hong Kong.

So that my first research project was really studying these experiences of families in Hong Kong and navigating assessments, navigating diagnostic pathways. And that was kind of the first, one of the first research studies that was published in Hong Kong about this area.

And that has kind of set the foundation, I think, for the rest of my career in terms of really working with families during assessments, during feedbacks, helping them find evidence based intervention for their kids. So, yeah, so that was kind of my first, first research study.

Brittany: 00:07:06

Cool.

Shawna: 00:07:06

Very cool. Thank you for sharing. And then that has sort of like led you to be more interested in this population, I would imagine, looking at autistic children.

And then you've obviously, as part of your dissertation, looked at some of the barriers from an economic or socioeconomic sort of standpoint as well as, like cultural as well. Knowing that ABA is not being done globally and certainly even here in Canada.

Really, like when I became a behavior interventionist, it wasn't behavior analysts that were supervising that service, because there just wasn't really behavior analysts and so the field is, continues to evolve and we keep learning and growing. How did that sort of lead you into this interest into pda?

Hilda: 00:07:51

That's a great question. So pdai, this really came about post grad school.

So this, you know, according to definitions, I am still quite early on in my career, so I'm within kind of five years out. And so for me that also means that I have the most up to date knowledge in terms of grad school.

What we were teaching and PDA never, never came about during that time. So I think when I first, I didn't start, I didn't, I wasn't aware about PDA until I moved to Vancouver.

So this was so just to you a little bit of context. I did my grad school training in Toronto and then I did my postdoc training in California and then I moved to Vancouver.

So it was much later when I became a registered psychologist that I started hearing families talk about pda. This has never come across, I've never come across this prior to that. And so it came about, I think initially while I was working at the hospital.

And at that time PDA, it's not a DSM 5 diagnosis. So for me, I was just, my thought initially was that, okay, well, it's not a DSM 5 diagnosis.

My area is in autism, so I'm just going to focus on autism. But then as I continued working with families, this came up a lot more.

And so at this point I was like, okay, well I really need to understand why parents are asking me about this. So how this came about was that I started having a lot of conversations with families to kind of teach me what they were learning.

So I, you know, I did my own kind of quick Google search, but I thought was what was really helpful was having parents send me what they were seeing on social media. You know, some of the workshops, some of the courses that maybe they were taking or were interested in taking.

And that's kind of how I started learning more about pda, at least in the way the families I was working with were understanding. What?

Brittany: 00:09:42

Right.

Shawna: 00:09:43

And then I think the interesting question is like, what is PDA really? Right? And like you're saying it's not in the DSM 5.

And so for parents listening, that's the diagnostic statistic manual for that you psychologists will use, right? To diagnose various things, including autism. But PDA is not in there. And so what is it?

Hilda: 00:10:03

Yeah, that's a great question. So when I started talking more families, I was like, hey, I need to learn more.

Like As a clinician, these are important questions that families are asking me and they trust me with these questions. So that was actually my first thing was to define what PDA is.

And because it is not in the DSM 5tr or the text revised version and it's not in the icd, which is the other diagnostic manual that the WHO uses, it was really challenging for me to find out what that definition is.

And so I then went through, there's a PDA society that I kind of looked at their definition and then through social media everyone kind of had their own definition and it sounded similar, but they were also quite different from each other. And that was kind of the first challenging part is to define what PDA is.

And the reason why we do have a diagnostic manual is to kind of counteract this. Right. Is to give us a common language to talk about certain diagnoses is to give us very standardized criteria.

And one of the main challenges, and I think we'll talk a lot more about this later on, is the definition of pda.

It hasn't been operationalized in a way where when I say PDA or when you say PDA or when a family says pda that we realize that we're actually talking about the same thing because we don't have that standard language right now to talk about pda.

Shawna: 00:11:22

Right, right. And so this pathological demand avoidance is the long name, has like some inferences about what it might be about. Right.

Like demand avoidance and then the pathological part being like it's probably happening frequently. And so we can infer maybe some ideas about what PDA could look like, et cetera.

But what you're saying is there's no real standardization in that definition, correct?

Hilda: 00:11:49

Absolutely. Right. Not in the way that we would want to have when we are thinking about having a diagnosis and then how

Brittany: 00:11:56

hard for families if you are wondering and then going down a Google deep drive or social media deep dive, sorry, not drive is like, then I'm finding all kinds of misinformation likely if there is no standardized definition. And like I could be taking a course that's really like could be, I don't know when I say like non factual, but it could be right.

Like depending where it's coming from.

Like that's kind of scary thinking about that as a parent that I could just like I'm trying to find all this information out but there's nothing really, I don't know, authentic or how would you describe that?

Hilda: 00:12:28

Oh, absolutely. And so I think I'll also give a little Bit of context, kind of about my training.

So I was mentioning how a lot of my research has been on parent perspectives on evidence based care. And it is so hard for families and kids and individuals to find good information out there.

I mean, we have so much information, but the quality of it is very, it's, it's. There's a huge spectrum on the quality of information. So it's definitely challenging for families.

And I think what's tricky for so, so in talking about kind of my background, a lot of my work has been to try to teach families and try to teach parents how to find, how to access this quality information.

The tricky part about social media and even I, you know, when I first started pd, talking about PDA and researching, my first, my first kind of search was through Instagram because I want to know what parents are seeing, what families are seeing. And there's so much, so much information and a lot of it.

If you don't have the research background or the clinical background to kind of filter this information, it does look authentic, right? Because there are, I think what's challenging about picking. And I'm not just talking about pda, I think I'm talking about kind of any. Really. Exactly.

Right. I think any diagnoses or definition, there are parts of it that is true.

There are areas of the definition or some posts that there's like a little sliver of truth. But then there's a. It's kind of shrouded in a lot of also misinformation or it's maybe missing the nuances. Where. Yes.

You know, when you have a TikTok video, it's 30 seconds. Can't. Nobody can really talk about the nuances of a certain disorder or intervention or et cetera. And I think that contributes to the misinformation.

Shawna: 00:14:16

Right. And then through this work and this dive that you've done, and I do think this comes up, I often say in the autism world a lot, right.

There's a lot of fad treatments out there and sort of new stuff that's always coming out. And so I think early on in my career I learned to be sort of skeptical and evaluate things.

Um, and now that I'm a parent, though, I am also getting a ton of information all the time about how to be like a gentle parent and what, what is that? Right. And then I'm as a clinician sort of lucky, right. I can take like a second level of thinking to this.

But if I'm a parent out there or maybe even like a school staff, is someone that's coming to mind that was asking for us. Like I think I have a learner that maybe has PDA or like is presenting as someone that has pda. How do I find good quality stuff out there?

How do I vet what's out there? Did you come across any like sort of good tips and strategies that people might be able to benefit from?

Hilda: 00:15:06

Yeah, I think besides going to get a PhD and learning all these research strategies, that would take quite a long time. So in terms of kind of telling parents how to find good quality research, I often do advise parents to use something called Google Scholar.

So that's something I often use.

It is more specific to peer reviewed research versus if you Google something on just typical Google, it's going to show you a bunch of different information. But if you go on Google Scholar it focuses on peer reviewed research mainly. And so even within peer reviewed research there's different tiers.

I often tell parents to try to look for systematic review. So you would just put in systematic review and then you would add say autism intervention or TDA, et cetera.

And why I always focus on systematic reviews is that it kind of looks at a systematic review, looks at all of the research that's available on one certain topic.

So it's not just one research, but it's like, okay, how much research is there about X intervention and what is the quality of the research that's out there?

Because I think one of the things that's kind of missing in our day to day discourse about research is that yes, published research is good, peer reviewed research is good, but there's different quality of research.

So you can have research that has a sample size of 1 versus research that has lots of different, you know, they're considering lots of different variables. They have a much bigger sample size. So there's different tiers of research as well.

And the systematic review does a really good job kind of summarizing what's out there at this moment. So if parents do have a, you know, a question about a specific autism intervention, that's what I would suggest them to do.

Shawna: 00:16:51

Yeah, I'd love that. And actually not a strategy I've ever suggested to a parent. I myself use Google Scholar all the time, of course.

And I think the idea of making this, this approachable, right. It's not just people that have PhDs that can read this stuff.

And certainly as a parent just reading the abstract, right, the beginning part there of the systematic review can give you a lot of information. It's not that you need to understand like statistical Inferencing and like that sort of stuff. Right. You can get the.

Still understand it without having to digest the entire article.

Brittany: 00:17:22

And I was gonna.

Hilda: 00:17:23

Absolutely. And I think.

Brittany: 00:17:24

Oh, sorry. I was gonna say, what about those parents that don't feel comfortable doing that?

But I think you answered that, Shauna, is like, read the abstract or like I.

And in the introduction, then that's where you're going to get a concrete definition of something or like multiple variations of a definition of something. And so it'll say like in some research describes as this or this.

And then in that intro you're getting like potentially that information you're looking for as a parent. It's like, oh, here's like everything we know about this topic just in the introduction.

Shawna: 00:17:50

And then do you find the fact that it's not in the DSM to be problematic in finding research about it? I would imagine, yes. Is. Is that your experience about PDA specifically?

Hilda: 00:18:02

Yeah, yeah, yes, yes. And I think so. Maybe I'll talk a little bit about when I kind of use that strategy.

I just talked about the systematic review is that there aren't a lot of good quality research about PDA right now. I think that is. That makes sense given the stage of research we have a pda. It is very beginner stage. This is what we usually expect with.

With emerging, emerging kind of theories where there is not a lot of good quality data. So that's kind of where we're at with PDA right now. So, yes, it does make it tricky because it is not a DSM 5 or DSM.

I think we're coming up to a DSM 6 soon, but it's not in the diagnostic manual right now. So it's kind of like the chicken or the egg. Right. We need research in order to prove something exists, to put it in the dsm.

But if it's not in the dsm, then we're not going to have much research about it because that. There's just not as much attention. Yeah. And so, yeah, so there is that trickiness because it is not in the DSM right now.

Shawna: 00:19:04

k came, I think, in the early: 2000

And when I started in the field as well, there wasn't one diagnosis. It was separated. Can you share a little bit about the history of that?

Hilda: 00:19:24

Yeah.

So when I first looked at social media and that definition of pda, I think the common definition was that this is a profile within autism And a lot of the social media accounts, they often reference this paper that was authored by a psychologist called Dr. Elizabeth Newsom. And back then, autism was defined differently. So just to give the viewers, or, sorry, the listeners, context.

rst written, this was back in: 2003

So we had something called pervasive developmental disorders. And there were five different categories under pervasive developmental disorders.

So this included autistic disorder, Asperger's disorder, PDD not otherwise specified, Rett disorder, and childhood disintegrative disorder. So all of this was considered under PDD or pervasive developmental disorders.

And this was the context and this was the timing of when her original research was created. And so for her, when she was talking about autism.

And she also does reference, actually when I was reading her, her article again, she does reference autism spectrum disorders. But this was 10 years before autism spectrum disorders as we have operationalized it in the newest DSM existed.

So her definition, she didn't really talk about specifically what her definition of autism spectrum disorders was in that paper. However, given that it was published 10 years before what our current definition is, I would assume it is different.

And I think that's where it's a little bit sticky because we're using a lot of very similar sounding words. But I do think when I, when I reference her original article that we are talking about different. A different definition of autism. Yep.

Brittany: 00:21:24

That's important context, for sure.

Shawna: 00:21:26

For sure. And then with that shift in mind, like, how does that.

Then today we don't have a standard definition for pda, but we're all saying we hear this all the time. Right? Parents coming in thinking, I wonder if my child has pda.

We, you're saying all over social media there's tons of people talking about this idea of pda. And so as a society, it seems like something like this must be out there. And where do we land today with like, what is PDA and where are the gaps?

Hilda: 00:21:56

Right, Absolutely. I think in terms of what we land on today is that first of all, I think it goes back to a kind of original question, is that what is pda?

We have to define it.

And I think when I look at, when I look at the lens through, okay, what the DSM 4 looks like when Dr. Newsom was creating her PDA definition and what does Autism Spectrum disorder look like now with our DSM 5 text revised version Is that if you look at the original criteria and how autism is defined as today, a lot of the criteria that she captured would be captured also by autism spectrum disorders today.

Shawna: 00:22:35

Right.

Hilda: 00:22:35

So from a clinical standpoint, everything she talked about, I'm like, yes, I see all of that in my day to day practice. However, given the changes in definition, what she saw as PDA would be considered under autism spectrum disorder as the definition.

Shawna: 00:22:53

Right. Okay. And so I think we're looking at sort of two different conversations almost. Right. One is like, why did diagnosis matter?

And then also, why don't they? Right. Again, like, people are talking about this and coming in, and so let's say I'm a mom coming in and chatting with you.

I'm like, I think my child has pda. It doesn't really matter to me if you have a diagnosis. This is something that you're sort of feeling.

What would be your response then to help them figure out what those next steps are? Maybe they have a diagnosis of autism and maybe they don't.

Hilda: 00:23:23

Yeah. So I think for me, I. This, I. This. I often talk about this during my feedback sessions. It's like pda, its relationship with. With autism.

I usually, what I do is I explain to parents what the autism criteria is and explain some of the things that they're seeing. So a lot of times in my, in my intakes and my referrals, parents are coming in like, oh, my child, you know, she is a bright kid, works really hard.

But there's some things, it's just so hard. Like, the mornings are really hard. You know, I know they can do all of these things, but they choose not to do it or they avoid doing it.

And those are kind of the words that they use. And that really fits with that PDA definition that social media has.

Brittany: 00:23:59

Right.

Hilda: 00:24:00

However, when we're looking through an autism lens, difficulties with following the transitions. Right. Rigidity, all of that also can be captured through autism. And so that's kind of how I explain to parents.

It's like, I do see what you're talking about.

However, I wonder if some of those challenges that you're seeing in the morning, is it due to the transition or maybe it's due to the sensory challenges. So, for example, brushing your teeth, that is a very, very typical challenge that a lot of the kiddos I work with have.

And so I kind of walk parents through that. Like, where this avoidance that you're seeing. Okay, where, where. What do you think the trigger is? Is it the sensory part of brushing your teeth?

Is it transitioning? From one thing to another or is it challenging?

Because, well, it's the, you know, if I don't brush my teeth and I don't have to go to school, like, is it trying to delay? So there's a lot of other reasons for this avoidance. And, and I think I'm like you in the way where the label. I know it matters to families.

Absolutely. But I think from when I'm looking at an intervention perspective, I'm really trying to look at, okay, what underlies that label.

Why are we seeing this avoidant? And I think that is more helpful for intervention than to just capture it as avoidance and then move on.

Brittany: 00:25:15

I love the way you framed that.

And I want to ask, as the speech pathologist in the room, this isn't my certainly area of like knowledge or expertise at all, but I was thinking about how we talk a lot about this sort of like blame and shame view of the. Of different behaviors or things that we're seeing in children.

And the flip side of that, like getting curious and understanding it and understanding sort of like what's underlying here and what you're talking like. I love the way you frame that because I feel like if I'm saying, oh, it's because of pda, like they just avoid.

They're avoiding all my demands and they don't want to. You can instantly feel like the. The def or the like, the title of that PDA implies this.

Like, well, they're bad or like, well, I mean, right in the title. Like, or they don't want to because of this.

And what you' nursing and how you frame it with parents or like how the intervention looks is like, well, let's take the step back. Let's get curious.

Because it could be that their sensory system is just really overwhelmed in this moment and brushing their teeth is hard and it's not like they don't want to or like they're just saying no because that's what they do. It's like there's usually some really like something underlying here.

And I think that's like such a more neuro affirming way of looking at things is it's not the kid is just like saying no to everything. It's could be for their system. This is really, really hard.

Hilda: 00:26:31

Yeah. Yeah.

And to kind of follow up on that, I think when I first read Dr. Newson's original study about PDA is that I noticed and again, this is very typical of new. New kind of research topics. It's just that you have a research question. You're like, oh, I wonder if this is. This is what's happening.

So you publish this. So this is very typical of the. Just the stage of research that this was at when, when this paper was conducted.

But she did note that she didn't, you know, she's noticing all of these avoidant behaviors. But she also reported that she didn't really look at iq, she didn't really look at language abilities.

She didn't look at all of those other areas that, you know, definitely if we have a child who has speech differences, they're going to avoid, but it's because of their challenges with speech. Right.

Or if we have a child who they're thinking at a younger age, yes, they'll say, no, they'll say, I don't want to do this, but it's not because they don't want to, but it's really because of there's a skill difference there and we got to address that, you know.

Brittany: 00:27:32

Yeah.

Hilda: 00:27:32

So the behavior looks the same, but we need to figure out kind of other reasons as to why this avoidance behavior is occurring.

Shawna: 00:27:41

Right. And I think that's where then potentially that specificity that would be required for a diagnosis. Right. And that's where that becomes important.

And if we don't have that specific specificity, like even going back to this newson article, you had shared it with us, it looks like there's like eight sort of key criteria that she had sort of found. So this passive early history in their first year, year of life.

So maybe not reaching for toys or are watching more than participating, continuing to resist and avoid the ordinary demands of life. So that one was something I would like, expect. Of course, it's like avoiding demands is exactly in the title.

Some of the other things, maybe lack of social identity or of pride or shame.

Some of the other things you mentioned, maybe their mood or their impulsive, comfortable, maybe role playing and pretending when they get to be the boss, but not really wanting to take on those other roles, maybe a language delay, obsessive behavior. And then I think the final component there being some sort of maybe neurological involvement like clumsiness.

And so when you take all, all eight of those things together, that's a different picture than isn't brushing their teeth.

And then like you said, I think one of the things that I've been very cautious of myself as a clinician is that the diagnosis or the label is kind of punitive in itself and it blames the child. It makes the child look bad when really it's like potentially something in the environment isn't going like isn't working well for them.

And then similarly, right, with autism we see that sometimes that diagnostic label is so helpful. Right. You get access to funding. Maybe it also gives an explanation for why you might not be responding to your name or that sort of thing. Right.

Gives us some insight into it.

But the name right now of pda, I feel like, I don't know in my clinical opinion, I've always felt nervous about it because it really does put sort of like a.

Well, they have PDA so they can't do, they won't follow any of my instructions and there's like a bad kid and there's nothing I can do because they have pda.

Hilda: 00:29:46

Right.

Shawna: 00:29:46

And then I feel like the label becomes like almost like the not empowering, like disempowering. Is that a word?

Brittany: 00:29:53

But I know what you mean and we've talked about this before too. Like giving that label to such a potentially a young child too could be so harmful on their confidence.

And then they, it's sort of like this self fulfilling prophecy is like, well no, everyone just kind of says like I don't do it so then I'm

Shawna: 00:30:10

not going to do it. And then I don't know, like chicken and egg again there.

Brittany: 00:30:12

Right.

Shawna: 00:30:13

And that's where that specificity maybe does matter. And that's what you're saying, seeing.

Hilda: 00:30:16

Absolutely, absolutely. And that's exactly what I was thinking. This, that self fulfilling prophecy.

And when I work with families a lot of times I do I talk about accommodations, but I also talk about it is balance. We can accommodate where we need to, but we also need to teach skills.

And I think, you know, when we talk about, when I see some of these social media programs out there for pda, I, that is my worry is that we're only talking about accommodations. So things like perhaps removing certain demands.

I worry about what that might look like in the future because I know currently, yes, with any avoidant behavior. So let's take anxiety for example. Avoidant behavior is like a cornerstone of anxiety behavior. I am afraid of something, I am going to avoid it. Right.

So right now in anxiety, one of the best interventions we can do is exposure therapy, which is we kind of face this, this thing that really scares us in a, in a, in a way where we know starting at a. From a kind of a low, low end of the hierarchy where we move our way up to the highest part where we're really facing the thing that's really scary.

But we're starting low, we're starting small. First and slowly building up to that. Right. That's exposure therapy.

Now if we remove the stimulus, so say, I don't know, I'm scared about let's say like public speaking, which I'm doing right now. Right. If I'm saying okay, like let's, and we're saying okay, like let's remove that totally. Let's, let's, let's have Dr. Ho avoid public speaking.

Brittany: 00:31:46

Right.

Hilda: 00:31:47

Totally.

Brittany: 00:31:47

Indefinitely.

Hilda: 00:31:48

I'm going to feel so much. Exactly. I am going to feel so much better. Right. So of course my emotions are going to be stable, I'm going to be great.

But then I'll never be able to develop this skill. Right, right. And public speaking or speaking in front of a classroom, speaking to other people, that is, is really important.

So I worry about some of these social media kind of recommendations out there where we're just talking about accommodations and we're not talking about strategies to support these kids into building specific skills.

Shawna: 00:32:18

For sure. And you know, I saw one of those posts recently talking about how unkind exposure therapy is.

And in my brain I thought, ah, this is oops as such a missed opportunity. Because exposure therapy in behavior analysis we might call it, sometimes like a little bit of behavior shaping.

And oftentimes we'll say like the learner, the person you're working with, you really don't want them to know that you're pushing that next step forward. Like they, it should almost not be detectable to them.

And with exposure therapy done right, it's really the person that's driving what that exposure looks like. And so it is, is still person centered. And in this post that I saw, I felt like it was like putting psychology back like 30 years, you know.

Whereas now like you said, exposure therapy is important because I have goals and things that I want to do in life.

You know, I have a life that I want to live and if I just start taking away all the things that are scary to me, then how am I ever going to develop the skills to do them?

And so anyways, I thought with this exposure therapy post that I'd seen saying how is bad and it's not neuro affirming care and all this, all these like buzzwords, I thought, yeah. But then also I don't think you know what exposure therapy is when it's done. Right.

Hilda: 00:33:36

Yeah, I completely agree. I completely agree. I think that and I think that maybe segues into another part where we talk about.

So oftentimes I talk with families like evidence based intervention is super important. But the other part that's also really important is the. Your clinician, the person that is delivering this.

So we're saying exposure therapy works, we're saying behavioral therapy works. We're saying speech intervention is excellent, but it also depends on the quality of your clinician. Right. And I think it's. It's also.

It's quite sad sometimes as I work with a lot of families and. And I say these, you know, like, you should try these things. And they do try it. They absolutely try it.

But unfortunately, their clinician, that rapport with their child, that report with their family, or the way that intervention is being delivered is just not. It's just not in the way that you're supposed to deliver it. Right? And some parents and families, they. They have this.

Then they think, oh, okay, well, you know, it must be because this intervention doesn't work.

Brittany: 00:34:33

Right.

Hilda: 00:34:33

But it might be because of the way it was being delivered.

Shawna: 00:34:36

Absolutely right, Exactly. And I think with PDA and really our mentality around all of the approaches that we take is that we want to get curious, us first.

And so if I'm a teacher or an educational assistant or a parent of a child who seems like, whatever, whenever I ask them to do something, they tell me no or I get pushback, right? Would probably be like, mostly what people are talking about when they say pda.

My first thought is like, okay, let me step back and think, like, is it always when we're brushing our teeth or like, can I find some patterns here to when this type of thing is occurring? And then what am I?

Hilda: 00:35:10

What.

Shawna: 00:35:11

What can I do? Can I take some pressure off right away? You know, like, can I sort of make things easy for a little bit? Let us get back and connect, right?

We know, get curious and connect being that first place for intervention. Right?

And like you kind of said, if you have a therapist that wasn't able to connect and really understand that, then the rest of this doesn't really matter. If they could follow all the best research, but if you haven't connected, then like, whatever you do next doesn't matter potentially.

And so get curious and connect and then start thinking about how much.

How can we take these really small steps forward to help them make the teeth brushing easier, or if it is doing academic demands, right, we might see lots of pushback. Okay, can we get curious about the rest of their sensory system and how's that working? Is the classroom functioning well for them? Can I give them.

Where can I give little bits of control? You know, and we talk about that a lot as parents, too.

And I'm often, even in my own life, I don't have children with pda, but often saying to my husband, like, you know, like, does it really matter if they do that thing? And could we just be a little bit more flexible, too, instead of pushing through?

And sometimes I wonder, with PDA in particular, because of the way it's branded, people have already a conception about who this kid is.

Brittany: 00:36:26

Definitely.

Shawna: 00:36:27

Right. And so we're automatically coming in and clashing.

And then at that point, as the adult, I'm not going to back down because I'm the adult and you should do what I say. Right. And then you get into this big friction, and then this kid has now this diagnosis of PDA potentially.

And so I think that idea of getting curious and stepping back and then thinking, what are some small ways that I can help you overcome some of these things where your nervous system is saying no?

Brittany: 00:36:54

Yeah, exactly.

Shawna: 00:36:55

Do you have any strategies and stuff that you recommend that are sort of easy things that parents could think about, like, oh, if your child is displaying what you might classify as PDA or demand avoidance, what are some of the things that the research does say work?

Hilda: 00:37:10

Yeah, so I think that's. That's an excellent question. I think for. I'm going to kind of go go on a tangent a little bit first.

Before talking about that, I think, you know, when I was reflecting a lot about pda, like why, you know, parents are talking to me about this, I do think a lot of it is the assessment process for autism. So just to give a little kind of background, especially in a public sector, when you are working in an autism program.

So a lot of times it's like, there's really long wait lists. So the focus really is, does this child meet criteria for autism? Yes or no?

However, we do know that there are a lot of comorbid disorders with autism right there. Learning challenges often, or attention challenges. Kids are at a higher risk for a lot of these other areas.

However, in a public system or most public systems that I've worked at, it's that this is our main goal, is to just say, okay, is this child meeting criteria for autism? Yes or no. What this means, though, is that we don't have data on their cognitive abilities. So if their cognitive.

If their thinking abilities are different, different, if their learning different abilities are different, if their attention, their attention differences, or their emotional differences, we don't really have the ability in most public programs to assess all of that just because the wait list, like for here, for example, in bc, it's Almost three years long. Right. So we don't have the ability to have such a comprehensive assessment, so. Which makes it tricky about intervention.

So right now you're asking, is there like. Like, an easy way or a very simple way to kind of help parents?

And I guess my answer is, not until we have more information about all of these other areas. And so in private practice, I think the benefit of being private practice is I'm able to give a more comprehensive assessment. I can look at.

Is it learning? Are they avoiding writing because there is a writing challenge. Exactly.

Or there's having really big difficulty with sustaining attention, even though they put so much effort in doing that. Right. And so in private practice, I'm able to do that a bit more, and that can give me more pieces of the puzzle.

So when I'm talking about avoidant behavior, then I can be like, oh, okay, you know, your kiddo is struggling with writing. That happens often with kids who have a diagnosis of autism. And so I can see, okay, is the writing.

Because they're having challenges with their writing structure, just, you know, writing using specific words, that's challenging for them. Or is it difficulty with coming up with an idea, or is it a difficulty with their fine motor skills? I'm able to look at all of that.

So these are all possible reasons that can lead to that. Avoidance. And by being able to find. To have data on that, that can really help me with giving very specific recommendations to parents.

Shawna: 00:39:56

I love that.

Brittany: 00:39:57

And I think we've seen that certainly many times in the clinic. I'm thinking of a team that we have right now who came in and he was like, I can't read, and he has autism.

And he'd be like, nope, I just can't read and I can't write. And then when I dug deeper and did an assessment, I can't diagnose dyslexia here in Ontario.

But I can tell you that he met all of the clinical criteria for having dyslexia. And I'm like, well, no wonder it's so hard for him to read. And now he's like a teenager.

And so he never, like, he wasn't able to learn all of those foundational skills that now he's sort of able to just kind of give up. And you could see in that. That position, he's like, okay, no, I'm just avoiding writing. But of course you are. Like, you don't have that foundation.

Shawna: 00:40:36

He was, like, happy, though. Like, he wasn't, like, problem behavior for, like, demand avoidance.

Hilda: 00:40:44

Yeah, you're right.

Shawna: 00:40:45

Necessarily. But I was thinking similarly, like, with. We see like demand avoidance as a symptom or a characteristic of.

Of people that have autism or are neurodivergent, adhd, etc, and those things we know, again, like that executive functioning part of their brain is different. And then therefore it makes sense that you'd have different ways of giving demand avoidant responses too. Right.

Like in his case, he also, like, probably didn't know that he needed to communicate that, like, whatever those signs were of dyslexia, like that the letters were swimming, or like whatever the things are, he probably wouldn't have known because of that social communication deficit. Right, right. And then we've got other kids at the clinic that are more impulsive or have a trickier time regulating their emotions because of autism.

And then therefore, if it's a demand that's given to them all the time, then you might see them be.

You might classify them as demand avoided, when really that was like the best way they had to explain, like, I don't want to do that because of their autism or ADHD or whatever, you know, and that executive functioning impact.

Hilda: 00:41:50

Absolutely. And I think, if you see. I think my recommendation to parents is that if you do see avoidant behavior, that is the time to get curious.

I think to use your language, I love that word. Is because it's to figure out why your child's being avoided. Because any of those things we just talked about. If I.

So I don't speak German, but if we were to do this podcast in German, I would seem like I wasn't really paying attention to what you're saying to me. Right. I would seem avoidant. Yep. But that wouldn't be because I have this innate challenge with demands and things like that.

It would be because, you know, I'm not. I don't have the language to talk to. You do this podcast in German. Right. And I would probably avoid it because this is hard.

It would be hard for me to do something in German and I wouldn't be able to tell you in German that this was hard for me. Right. So even outside of the context of autism spectrum disorder, we can see how these behaviors. Yes, I'm avoiding. But there's different reasons.

And it's up to the job of providers to really figure out why this child is struggling so much. Right.

Shawna: 00:42:50

Versus slapping a label on them that then carries through with them forever. And like I said, as soon as you hear this demand avoidance as a label, you're kind of like, ooh, yikes. Yeah.

You know, especially in the school system, where there's like less training or maybe less time really to support this type of student, you just throw that label on them and it's like, okay, nothing I can do about that, you know? And so it's like, I feel like that's like a really nice full circle. They are for the, for pda. Yeah.

Brittany: 00:43:17

And I find, again, a little bit different. My kids are not, they don't have pda, but I find like, they will avoid certain things.

And I'm always telling them as a mom, like, we avoid things that we're not good at or just in general, you know, often it's like, okay, well we're not good at that yet. And so we're, that's why you're avoiding that. But let's take these tiny steps and let's like build that, that skill and practice a little bit.

I'm not saying it's that easy, certainly, but it's that idea of like, often we are avoiding something that's like either really hard or challenging. Like you said, I'm not doing this in German because it would be impossible for me. So I am going to avoid that. I don't know if that makes sense

Shawna: 00:43:52

in this context, but yeah, And I think for neurodivergent families, right, that's gonna be worse.

Hilda: 00:43:57

Yeah.

Shawna: 00:43:57

Right. Like your girls might say no to something or might be like, I don't want to do that.

But then what we're seeing with our neuroscience neurodivergent friends is again, that front part of their brain being different because of the diagnosis and knowing that the, their emotion regulation and impulsivity and that sort of thing might be trickier for them. And so the emotions show up louder, they show up bigger. Right.

And then that's where as a parent, maybe if they get this label, it feels like, ah, yeah. Comforting. Like, okay, it's not just me. Right. You know, it's like there is something different here.

And potentially what it all boils down to is that they were different from the beginning.

Hilda: 00:44:31

Right.

Shawna: 00:44:31

We already knew you had ADHD or autism or some, some sort of neurodivergence that then makes these, this demand avoidance show up differently and bigger and harder. And then as a parent, like I said, maybe that someone saying, aha, yes. You're like, oh, yeah, thank you.

Brittany: 00:44:47

Okay.

Shawna: 00:44:48

Because with my daughter this never happens.

And you know, and I, whereas with my son, I find every time I tell him to brush his teeth, it's this huge 20 minute meltdown and he's screaming at me, blah, blah, Blah, blah, blah.

Hilda: 00:44:59

Right.

Shawna: 00:45:01

And then you, I don't know, I feel like I can see where the diagnosis is helpful and might help parents or other people be like, okay, now I, I know that this is trickier for you, but could we get there with just an autism or ADHD diagnosis and thinking about this as getting curious about like when this is showing up?

Hilda: 00:45:18

I think so, yeah. And I think related to that, I think absolutely what you're saying, like a pda.

I think one of the pros about having a PDA label is that it does validate a lot of families and kids their experiences. Right. And I do wonder though, are there existing diagnoses in the DSM 5 currently that can also serve the same function?

And I think this also brings me back to kind of, you know, when my mandate while working a lot of public systems is that really we're focusing on autism. So I'm not, I don't have the time to assess.

I'm not given the time to assess for all of these co occurring conditions that could maybe explain some of these challenges. The families are feeling more.

And I think for clinicians out there, it might be helpful to add in some of those other assessment tools if you're able to, so parents can feel validated because they're seeing their child with autism. But they're like, okay, but I've seen other kiddos with autism and my child's behaviors are much more. Right.

And so if, if our assessment tools and our assessment tools are more comprehensive, then maybe parents are getting a better diagnostic picture.

So it's like, oh, my child has autism and a learning challenge or my child has autism, ADHD and anxiety, then maybe that can also serve the same function as validating the parents experiences without bringing in this new label that we don't currently have a consensus in terms of what the definition would look like.

Shawna: 00:46:42

Yeah, I love that. And great point about anxiety too. We haven't talked about that. And how of course, if you're someone that's anxious, that's going to show up. Right.

And I could see where someone that's anxious might look like they have demand avoidance, but really like you said, is that covered actually with their anxiety and that's the way it's presenting for them.

Brittany: 00:47:03

What an important takeaway though that you said, you know, there's this push to diagnosis, there's this lengthy, lengthy wait list and then once they finally get the opportunity to be assessed, it has to be done fairly quickly because of all of the sort of systemic issues there and often it's like a race to diagnosis in order to access funding, which there's another wait list.

But what you're saying is, like, if we had that chance to sort of slow down and look at, across different domains, how beneficial that would be and to look at cognition and language and, you know, all these different, different pieces, that that would be such a benefit to the child.

Hilda: 00:47:37

100 exactly.

Shawna: 00:47:39

Yeah, I like that. And even if you do have all the time in the world to assess, it's a lot of different buckets that you're assessing.

And that's sort of tying back to what you said initially, as well as it comes down to the clinician, too. Right. And I'm thinking sometimes we'll have young children go and get assessed or just like two, and just the pediatrician will just sign off on it.

Like they just write on a sheet of paper they have autism. And I think that's all the information sometimes parents are getting.

Hilda: 00:48:05

Yeah.

Shawna: 00:48:06

And then once you do the diagnostic assessment, once, you're not really doing it again.

Brittany: 00:48:10

Exactly.

Shawna: 00:48:10

And so if my child's diagnosed at 2, and then maybe they start therapy or something, you know, with us, we're doing, like, different assessments, but even ourselves, like, taking a step back and really trying to plot out into these broader categories, like, this is how this shows up for your child specifically, or this doesn't show up for your child specifically, and what that spectrum looks like for those things too.

Hilda: 00:48:33

You're right.

Brittany: 00:48:33

We had a family just this week that said it was like 15 minutes with the pediatrician, and they said there wasn't really an opportunity for discussion back and forth.

And I think in this case, they did say the doctor wasn't clear whether it was autism or not, but we both thought like, oh, wow, well, in 10, 15 minutes, often you can't get that information. And so then they were just sort of left like, oh, we don't know what to do next.

And that can be a really hard road when you're saying, I think something's different, but I don't know where to go. And you're sort of battling between the public system and the private.

And then if you are going private, you've got the time and maybe the opportunity to look at more things. But it's not cheap.

Shawna: 00:49:08

Right.

Brittany: 00:49:08

It can be really inequitable that way, where it's. Some families just can't access that.

Hilda: 00:49:13

Absolutely. And I think maybe this is a good time to also chat about the differences in different systems.

So previously I did do my training, I did my residency in Ontario, and you Guys have a very different way of diagnosing autism. As in, like there are different people can do it, you can use different tools. It's not very regulated in that way.

When I was doing my training in California, we did a same day model. So what we did was that we had a dev peds or a medical doctor, we had a psychologist, we had an OT and we had a speech therapist.

And the child would be under six because I only worked in an under six program at that time. And they would come in and we would do all of those assessments in one day and give feedback. So it was multidisciplinary.

Brittany: 00:49:55

I like that.

Hilda: 00:49:56

I know I had the same feeling as you both when I was reading up in this program and that's why I went to California because I'm like, I need to try this out. And then now I'm here in B.C. and it is more regulated.

So you have to do the ADOs, you have to do the ADIr, and there's certain clinicians that can do it.

So it is a very different system than Ontario and I think in some ways with families do prefer that because you get a very comprehensive autism assessment. Yeah, exactly. You know exactly why you're there, you know what these tools look like. So it is helpful in that way.

But it does take much longer versus in Ontario because you can use different tools.

Shawna: 00:50:37

Amazing what a phenomenal program that is. That would be so helpful. And like you said, not every autism assessment is, is the same. And certainly the families ask us that a lot too.

Like how do I know if I'm getting a good assessment? How do I know?

And unfortunately like you said, sort of the wait lists are long and for publicly funded ones you're like, the government has dictated what that experience is like. But even privately, right, you can go and pay for assessments and get some of those additional things done.

And if you have extended health benefits or something like that can be a way to get this additional information about your child. But it's certainly not accessible.

Brittany: 00:51:15

And then I thought you mentioned in our initial discussion, sort of prior to recording here that you, so obviously you're a psychologist, but then you do your assessments with a speech pathologist, is that right?

Hilda: 00:51:25

Yes. Yeah.

Brittany: 00:51:25

Tell us a little more about that. I love that collaboration.

Hilda: 00:51:28

I love to. Okay, so I work with this lovely speech therapist. I'm going to shout out Sarah. And so we run Saturday clinic. So here in B.C.

for kiddos under six you have to have a multidisciplinary assessment. It's a bit trickier in Private.

Because what this means is that up until actually November, the child, the family had to go see a pediatrician and get assessment. They have to see a psychologist and get a cognitive and an autism assessment and they also have to do a speech assessment with an slp.

But starting November, the pediatrician part is not necessary to complete the full assessment. But right now you still need the causative, you still need the autism assessment and you need the speech.

So what we do for our Saturday clinics is that we do a one day assessment. So I do the adir virtually. So that's the intake that I do.

I typically reserve about two to three hours to do an autism interview with parents virtually. And then we bring the child in. This was under six, kiddo. Saturday.

And Sarah and I, we do the speech assessment, we do the developmental assessment and we do the autism assessment in one day and then we give them feedback. And I love, I mean throughout my entire career I have worked with speech therapy.

So even back in, when I was working as a behavioral interventionist, we had an in house speech therapy team. So we were able to work as team members. So that was really nice. I've always been able to work with a speech therapist.

I think especially given the overlap when we're talking about language and social communication, we have to talk about speech. Right. So having Sarah, they're doing her speech assessor, I'm also able to watch her when she's doing the speech assessment.

It gives me additional information. She's able to watch me with the child. So I think it's a really good team that we do. We have for our Saturday clinics.

And I think just doing it in a one day as opposed to having the parent go out and do all of these assessments separately, I think a lot of parents do find that to be a benefit.

Brittany: 00:53:28

Oh incredibly, yeah. You mentioned the standardized assessment that you'll do in the parent interview.

Do you happen to know what the standardized assessment assessment is that the speech pathologist is using? It's okay if you don't. Or are they doing.

Is she doing a mix of like standardized and then sort of objective like things in play and like a speech sample and that kind of thing. Do you happen to know? I'm just curious.

Hilda: 00:53:49

Yeah. So in terms of assessment tools, I think it is a variety.

So oftentimes it is a standardized assessment to just see what the child's language level is like. There are opportunities for play.

So just watching how the child is playing with, with her or playing with the parents and she also gets to watch how the child is like, with me during the ada. So it's really nice because we get to see how the child interacts with a variety of different people.

And we also get a good language assessment to see what the child's language level is.

Brittany: 00:54:18

Like, I love that. I mean, Shauna and I do our assessments together and now I wouldn't really do it any other way. And so.

But I can appreciate it's a very similar dynamic then when you're like, okay, I know you're looking at this stuff, but then I'm also like, listening and learning. And then we sort of flip and like, I just love the collaborative approach when you do an assessment. And so I can see, like, huge, huge value to.

That is so cool.

Shawna: 00:54:39

Yeah, we talk a lot about taking a holistic approach and looking sort of beyond your own clinical lens and the value of everyone coming together a lot on this podcast and certainly with some of the other people that we've chatted with and can see that you guys also find the same.

Same thing is this both of you guys working together adds more value to the assessment process than doing them even the same assessments individually. It's really that collaboration that leads to a more robust interpretation of sort of what we're observing.

Hilda: 00:55:08

Absolutely. And I think it's helpful when we also do our feedbacks together. Again, this is very. This is similar to how I used to do feedbacks back when I was at.

During my postdoc, where you have the whole team providing feedback so we could talk about. Okay, you say your child's language is, you know, maybe one or two years behind. Okay, what does that look like in the context of autism?

So we can talk about those two pieces. Rather than a parent hearing very different recommendations from different providers at different time points. That can be very confusing.

So I think doing the feedback together has also been helpful.

Brittany: 00:55:43

Yes, absolutely. I'll take absolutely the same.

So if we're kind of, of summarizing here the things that we've talked about, we've said that there's no clear definition of PDA and that if you were Googling just on the general Google page that you're going to get a mix. And then if you look at social media, there's some things that are. Have an element of potential truth or.

And then some things that could be a little gray area.

Shawna: 00:56:05

Right.

Brittany: 00:56:05

So there's no clear definition at this point. And it's not in the diagnostic manual, the dsm.

And then you've also also talked about, like, what your recommendation would be to parents, which is you do that systematic review and go look at Google Scholar and like see what is out there. And if you're looking for like, where's the high quality information that would be your go to.

And then if someone is coming to you and saying, well, I think my child might have something like this, like, tell me about it, your answer would

Shawna: 00:56:32

be like, let's take a step back,

Brittany: 00:56:33

get curious and talk about where are you noticing these times where things are more challenging and what, what does time look like when it's a little bit easier? And then what's the environment looking like when things are more challenging? Am I right so far? Yeah.

And then also looking at and seeing that sometimes even though your child might have like a diagnosis of autism, we might want to get curious again and look at some of the other pieces like language or cognition or attention or anxiety or, you know, all kinds of other things.

Hilda: 00:57:05

Absolutely. I think it's a great summary.

Brittany: 00:57:06

Okay, perfect. Is there anything else that you would say either to clinicians or parents on this topic that you would like?

Any last little tips or nuggets that you would give them?

Hilda: 00:57:16

I think for clinicians, I think it's, you know, like I said when I first started, when we first started talking about PDA and I first kind of was starting to hear it during, you know, talking to colleagues and families, my first thought was to also think like, okay, this is not in the DSM 5. As a clinician who works with this diagnostic manual, because it's not in this manual, I'm not going to talk about it.

And then kind of as through my journey, learning more about pda, I am talking to families. I can understand how dismissive that could feel. Right. And I think.

So I can really validate clinicians who feel this way where you're like, okay, I want to really focus on being evidence informed. And I don't really know what to do with this PDA label because it's not in the dsm. So I can understand that feeling as well.

So for me, I think, number one, it's like I validate clinicians. I get how it's tricky. And you might not want to talk about PDA because you never learned about it just like me.

At the same time, to also maybe give them a heads up that this could feel dismissive for families.

And I think my, and I would actually, so this is my personal view, but I think most providers would feel the same way, is that we're not saying that these avoidance behaviors are not happening.

now, Dr. Newsom was saying in: 2003

And so right now, I think that might be helpful for clinicians when they're talking about PDA to validate families to be like, yes, I do see these avoidant behaviors, to have a very honest discussion. And again, a discussion. So. Which means this is open to parents, there is a back and forth to talk about. Okay. But this is what the research is like.

So just to. If families are thinking about Googling systematic review and pda, there's only two systematic reviews right now talking about pda.

The amount of research we're talking about is probably around like 25 research articles. So there's not a lot of evidence to support this right now.

And so as a clinician, I would encourage you to look at the systematic reviews, I would encourage you to look at the original article by Elizabeth Newsom and to see if you come to very similar conclusions as I did when I read it. So I think that's my first one.

And I think the second part that I would also tell clinicians is to just to continue having that open discussion with parents. I think to have parents also show you what they're seeing on social media.

I found that was really helpful for me because even pda, what was defined by the PDA society or what is defined by a specific social media influencer, they're very different. So I. So I also actually joined some free workshops on PDA just to see what some of these families were seeing for me to understand.

So I think for clinicians, again, to keep that curious mind, to be open to these things that parents are seeing and to really try to understand it by immersing yourself in the literature that they're seeing as well so you can help your families better.

Brittany: 01:00:23

I love that.

Shawna: 01:00:23

Fantastic.

Brittany: 01:00:24

Wish we could work with you all the time. I wish we could stand our families,

Shawna: 01:00:29

your perspective on it.

Brittany: 01:00:30

Everything is so human, right? Like, you can't just avoid a topic because of X and you can't, like, you want to be kind and like, really look at things from a holistic perspective.

So thank you so much. What a nice conversation. We're so, so glad to have you here on the podcast.

Shawna: 01:00:44

Yes, thanks for joining us, Dr. Hilda Ho. We're really thankful for your insight and experience and expertise.

And so thanks for sharing your clinical wisdom with us today and hopefully we'll chat again with you soon.

Hilda: 01:00:56

Thank you. So much. I'd love that.

Shawna: 01:00:57

Perfect.

Brittany: 01:00:59

Before we go, we want to remind our listeners the topics we discuss in the podcast are not a replacement for professional medical advice. Please contact a professional if you have questions.

Shawna: 01:01:08

And just a heads up, we'll use both identity first and person first language to respect different preferences. We'll also see treatment and therapy since we come from a clinical space, but always with respect and a focus on what works for each person.

Brittany: 01:01:20

See you next time.

Shawna: 01:01:22

Bye.