The Hidden Harms of Exposure Therapy for PDA

More than once, I've worked with PDA parents in coaching or therapy, and they've asked, "If the root of PDA demand avoidance is anxiety, why wouldn't we just do exposure therapy?" Many of these parents have had experience with exposure therapy before, either for themselves or their other children, and found it to be helpful. So why wouldn't that be the case for PDA?

Exposure therapy is commonly used to treat anxiety in both adults and kids and relies on gradually increasing a person's tolerance to feared situations or stimuli. The idea is that safe, repeated exposures decrease fear over time. But for people with Pathological Demand Avoidance (PDA), this approach can majorly backfire. Here's why.

PDA Isn't Just Anxiety. It's a Threat-Based Need For Control.

In PDA, demands (even seemingly small ones like answering a question or showering) are processed by the brain as threats to autonomy. Exposure therapy views avoidance as a fear to be overcome, but in PDA, avoidance is a protective mechanism. PDA avoidance serves to regain control and isn't necessarily connected to a fear of the situation. Instead of decreasing distress, repeated exposure can make the threat response worse, increasing anxiety and avoidance.

Exposure Therapy Often Ignores Autonomy, and PDA Kids Will Defend It Fiercely

PDAers are highly sensitive to perceived control or coercion, and exposure therapy usually involves a structured plan led by the adult. Even when the treatment plan is gentle, if the child senses they're being guided towards compliance or an adult-directed goal, it can trigger extreme avoidance, shutdown, or explosive behavior. Through a PDA lens, exposure therapy can feel like manipulation, even with good intentions from parents and therapists.

Progress Depends On Desensitization, Not Co-Regulation.

Exposure therapy focuses on reducing sensitivity through repetition, while PDA support requires building felt safety through trust, relationship, and collaboration. The child's brain is only open to growth and tolerance once it truly feels safe, and that safety is built through connection, not confrontation. In PDA, stretching tolerance has to be child-led, in small doses, and only when deep trust and safety are on board.

Exposure Therapy Misunderstands the Underlying Reasons for Avoidance.

Through the lens of anxiety, avoidance is seen as an unhelpful pattern. In PDA, avoidance is essential for regulation. Forcing a child to remain in a stressful situation (even in small doses) can break trust, lead to trauma, and teach kids that adults will override their boundaries. Respecting avoidance as communication is key to long-term growth for PDAers.

So what actually helps?

Instead of exposure therapy, PDA-friendly approaches look like:

• Reducing overall demands and stress
• Following the child's lead
• Offering indirect invitations instead of direct instructions
• Strengthening relationships through co-regulation and felt safety
• Waiting for natural curiosity or internal motivation to emerge

Exposure Therapy Isn't a Fit For All Anxiety Anyway

Even in the wider world of anxiety treatment, exposure therapy isn't a one-size-fits-all solution. Research and lived experience show that many people (including neurodivergent adults and kids) don't respond well to exposure-based approaches.

Why? Because it prioritizes behavioral outcomes over emotional safety. It focuses on helping someone tolerate a distressing experience rather than asking why the experience is distressing in the first place or whether the distress holds clues about the nervous system, unmet needs, or personal boundaries.

For kids with differently wired brains or trauma histories, exposure can quickly feel more like repeated overwhelm than healing. And for PDA kids, it often fails to account for the core need for predictability and control. It can also unintentionally send the message that the goal is for kids to appear "less anxious" or more compliant, rather than supporting them in truly feeling safe.

Avoidance is the message, not the malfunction.

That shift matters for all kids, but it's essential when supporting PDAers who aren't just anxious about "the thing" but anxious about the loss of control itself.