Practicing psychologists’ accounts of demand avoidance and extreme demand avoidance in children and adolescents

Abstract

The construct of pathological or extreme demand avoidance (EDA) is used to describe the experience of avoiding demands and having an extreme need for control. However, the EDA construct is contested by researchers and educational psychology practitioners. To investigate the utility and validity of the construct of EDA, this qualitative study explored psychologists’ experience and conceptualisation of demand avoidance and extreme demand avoidance, and their approach to working with children and adolescents who avoid demands. Online semi-structured interviews were conducted with 12 psychologists (female = 9) working in private, education and disability services. Thematic analysis yielded six themes: (i) reason for the psychologists’ involvement, (ii) psychologists understanding of child’s presentation, (iii) psychologists’ focus in supporting the child, (iv) challenges for psychologists, (v) enablers for psychologists and (vi) success for psychologists. Results indicated that psychologists do not view the construct of EDA as necessary for their work and achieve success with children who avoid demands by drawing on range of approaches focusing on the underlying needs of those children.

Full text

Frontiers in Education 01 frontiersin.org
Practicing psychologists’ accounts
of demand avoidance and
extreme demand avoidance in
children and adolescents
LaurenHaire
1
*, Jennifer E.Symonds
1
*†, JoyceSenior
1 and
UgoPace
2
1 School of Education, University College Dublin, Dublin, Ireland, 2 Human and Social Sciences, Kore
University of Enna, Enna, Italy
The construct of pathological or extreme demand avoidance (EDA) is used to
describe the experience of avoiding demands and having an extreme need
for control. However, the EDA construct is contested by researchers and
educational psychology practitioners. To investigate the utility and validity of the
construct of EDA, this qualitative study explored psychologists’ experience and
conceptualisation of demand avoidance and extreme demand avoidance, and
their approach to working with children and adolescents who avoid demands.
Online semi-structured interviews were conducted with 12 psychologists
(female = 9) working in private, education and disability services. Thematic analysis
yielded six themes: (i) reason for the psychologists’ involvement, (ii) psychologists
understanding of child’s presentation, (iii) psychologists’ focus in supporting
the child, (iv) challenges for psychologists, (v) enablers for psychologists and
(vi) success for psychologists. Results indicated that psychologists do not view
the construct of EDA as necessary for their work and achieve success with
children who avoid demands by drawing on range of approaches focusing on the
underlying needs of those children.
KEYWORDS
adolescence, children, demand avoidance, extreme demand avoidance, pathological
demand avoidance
Introduction
e construct of extreme demand avoidance (EDA) was created to refer to children and
adults who persistently and vigorously resist ordinary demands owing to their need for control
(Newson etal., 2003). However, the evidence base supporting EDA is small, the construct does
not appear in diagnostic manuals upon which psychologists rely, and dierent diagnostic
thresholds are described in the existing research (Woods, 2022c). Disagreements exist as to
whether EDA occurs within autism (Stuart etal., 2020), across proles (Gillberg etal., 2015), as
a collection of symptoms in autism and beyond (Green etal., 2018) or is a distinct developmental
prole (Newson etal., 2003; Woods, 2020).
Whilst some psychologists, e.g., Phil Christie have authored books discussing likely helpful
approaches for demand avoidant children, empirical studies have not investigated how
psychologists support children with demand avoidant behaviour or whether the construct of
EDA is relevant to psychologists’ work (Kildahl etal., 2021). is lack of research into practice
has resulted in a lack of clinical guidance for psychologists about how to support children with
OPEN ACCESS
EDITED BY
Richard Woods,
London South Bank University, UnitedKingdom
REVIEWED BY
Judy Eaton,
King's College London, UnitedKingdom
Devon Price,
Loyola University Chicago, UnitedStates
*CORRESPONDENCE
Lauren Haire
lauren.haire@ucdconnect.ie
Jennifer Symonds
j.symonds@ucl.ac.uk
†PRESENT ADDRESS
Jennifer E. Symonds,
Faculty of Education and Society, University
College London, London, United Kingdom
RECEIVED 27 May 2023
ACCEPTED 23 November 2023
PUBLISHED 18 December 2023
CITATION
Haire L, Symonds JE, Senior J and
Pace U (2023) Practicing psychologists’
accounts of demand avoidance and extreme
demand avoidance in children and adolescents.
Front. Educ. 8:1230014.
doi: 10.3389/feduc.2023.1230014
COPYRIGHT
© 2023 Haire, Symonds, Senior and Pace. This
is an open-access article distributed under the
terms of the Creative Commons Attribution
License (CC BY). The use, distribution or
reproduction in other forums is permitted,
provided the original author(s) and the
copyright owner(s) are credited and that the
original publication in this journal is cited, in
accordance with accepted academic practice.
No use, distribution or reproduction is
permitted which does not comply with these
terms.
TYPE Original Research
PUBLISHED 18 December 2023
DOI 10.3389/feduc.2023.1230014

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EDA, which is signicant, owing in part to the high levels of stress
experienced by those children (Gore Langton and Frederickson, 2016;
Doyle and Kenny, 2023).
e aims of this study were thus to (a) explore how psychologists
conceptualise, experience and approach demand avoidance in
children, (b) determine if any accounts of demand avoidance are
conceptualised by psychologists as extreme, i.e., EDA and (c) identify
if there are parallels between psychologists’ accounts of EDA and the
construct of EDA presented in the literature. e study of
psychologists’ accounts will help to identify useful practices in
supporting children with demand avoidance and will advance the
conceptualisation of EDA by identifying if the construct of EDA is
something that is relevant to psychologists’ work. Such contributions
to the knowledge base are critical to support vulnerable children.
Extreme demand avoidance (EDA) is a behavioural prole
characterised by an extreme anxiety driven resistance to ordinary
demands and was rst described by Newson a clinician, and her
colleagues in the 1980s as a pervasive development disorder. Features
were identied by Newson etal. (2003) (see Table1), when children who
were referred for autism assessment were qualitatively dierent than
autistic children but similar to each other. e topic has garnered much
media and parent attention predominantly in the U.K., but the evidence
base on the features of EDA is lacking (Kildahl etal., 2021). Research
that does exist is informed by a variety of perspectives largely clinicians,
namely clinical and educational psychologists (e.g., Judy Eaton, Phil
Christie, Judith Gould, Norah Frederickson) and psychiatrists (e.g.,
Christopher Gillberg, Johnathan Green) as well as academics interested
in the eld (e.g., Richard Woods, Elizabeth O’Nions, Alison Moore).
Owing to the broadening of criteria for autism in the DSM-5,
researchers now see more commonality between what weunderstand
as autism and Newson’s description of EDA (e.g., Kildahl etal., 2021).
Eaton and Weaver (2020) describe that though there were non-autistic
people in Newson’s research, they would now likely meet DSM-5
criteria. Autism makes a unique contribution in predicting EDA
(White etal., 2022) and many UK authorities such as the Department
of Education and charities recognise EDA as a prole within autism.
us, in explaining EDA, features of autism have been used including,
sensory sensitivities, phobias, extreme rigidity, need to conform with
expectations (O’Nions etal., 2018), inertia (Milton, 2019), reduced
importance of social feedback (O’Nions and Noens, 2018) intolerance
of uncertainty (Stuart etal., 2020), cognitive inexibility (Malik and
Baird, 2018), executive function diculty (O’Nions and Eaton, 2020)
and monotropism (Woods, 2018). A dierent understanding of
hierarchy (Moore, 2020) and the role of trauma have also been noted
(Woods, 2019). O’Nions and Eaton (2020) concluded that features of
EDA are common in autism but that EDA appearing at the level
described by Newson described is rare.
Others reject the acceptance of EDA as occurring in autism,
describing a lack of consideration for possible alternative explanations
recognising that it instead represents a positive source for vulnerable
people, reecting power dierences at play (Woods, 2020). Research
indicates EDA may occur outside of autism, within other proles
(Daern etal., 2007; Reilly et al., 2014; Gillberg et al., 2015), as a
collection of symptoms (Green etal., 2018) or as a distinct prole,
tting within the obsessive-compulsive related disorders (Woods,
2022c). Some people have compared EDA to ADHD (Egan etal., 2020),
anti-social personality disorder (Trundle etal., 2017) and attachment
disorder (Milton, 2018). Malik and Baird (2018) acknowledge that for
EDA to beconsidered a distinct entity, it would require that all features
are not suciently explained by other disabilities or disorders. In trying
to elicit common experience, Kildahl etal. (2021) notes using existing
criteria of, for example anxiety, may be helpful, particularly when
aiming to provide early support. O’Nions etal. (2014) cautions that
attention should bepaid to common underlying mechanisms. Much of
the existing research does not focus on underlying mechanisms and
instead relies on Newson’s criteria (White etal., 2022), the validity of
which has been questioned (Kildahl etal., 2021).
Explanatory information about EDA could be garnered by
eliciting lived experience, biographies such as that co-authored by
Fidler and Daunt (2021) are helpful, however, the inclusion of such
voices in research studies has been lacking (Kildahl etal., 2021).
Some autistic people are highly critical of the construct, rejecting it
entirely, viewing it as undermining autistic self-advocacy (Moore,
2020) and as part of an agenda to make autistic people more
neurotypical (Milton, 2013). Demand avoidance, considered in this
way, sees autistic people as logically avoiding demands set by
neurotypical people who have dierent experiences of
communication, sensory information, and anxiety. Whilst the term
extreme describes the level of avoidance in this paper as used by
Gillberg (2014) and Reilly et al. (2014), Woods (2022c) describes the
avoidance as rational in conveying the autistic perspective.
Lack of consensus means that the construct does not appear in
diagnostic manuals such as the ICD-11 or the DSM-5, upon which most
psychologists rely (Raskin etal., 2022). It remains however, that some
children systematically avoid demands and parents and those identifying
with the prole feel that the EDA label is functional (Egan etal., 2020),
in helping individuals make sense of their lives (ompson, 2019).
Diculties with school (Gore Langton and Frederickson, 2016), as well
as high levels of family stress (Ozsivadjian, 2020) including parental
blame (Doyle and Kenny, 2023) have been documented.
e lack of validation of the construct of EDA means an absence
of clinical guidance about how to support children. e existing
guidance remains mostly neutral, documenting the divergent views
which exist concerning EDA, and largely does not address useful
practices. e National Institute for Health and Care Excellence
(2011) autism diagnostic guidelines and those from the Royal College
of Psychiatrists (2020), the Australia Autism CRC (2018b) and the
British Psychological Society (2021) all reference the absence of EDA
from diagnostic manuals and a lack of consensus on the construct.
Signicant interest in EDA was identied by both NICE in their 2020
review (National Institute for Health and Care Excellence, 2020) and
the Autism CRC (2018a) public consultation, however associated
guidance documents remain succinct on the topic. e National
TABLE1 Features of extreme demand avoidance described by Newson
etal. (2003).
• Passive early history
• Use of social manipulation
• Appears sociable but lacks sense of shame, pride, and social identity
• Switches mood quickly and is impulsive
• Appears comfortable with pretence and role play
• Language delay and unusual content
• Obsessively resists demands or focuses on people
• So neurological signs, e.g., clumsy, late to crawl, ts

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Institute for Health and Care Excellence (2013) also produced a
document specic to support strategies for autistic individuals, but it
does not reference avoidance of demands or how to support
experience of such. Both the National Institute for Health and Care
Excellence (2011) and RCP guidance note managing the presentation
as part of formulation and planning for the individual, whilst the RCP
version suggest avoiding confrontation but otherwise, do not specify
what may be helpful, aside from highlighting that avoidance of
demands is a common human feature. Interestingly, the National
Institute for Health and Care Excellence (2011) guidelines associate
EDA with oppositional deance disorder which may emphasise a role
of volition in avoiding demands, inconsistent with viewing avoidance
as a stress response. As well as publishing guidelines regarding
assessing for PDA (PDA Society, 2022), the PDA specic charity have
written at large regarding helpful practices for individuals experiencing
demand avoidance, with authors highlighting their annual conferences
are oversubscribed (Trundle et al., 2017). It remains however that
empirically based evidence as to what is helpful for this group
is lacking.
e research that does exist indicates that behaviourist-based
practices are unhelpful in EDA (Gore Langton and Frederickson,
2018), and may even becounterproductive (Duncan etal., 2011). is
is of interest, as some practices traditionally used in supporting
autistic individuals are derived from behaviourism, e.g., applied
behaviour analysis (Lovaas, 1987). e use of unhelpful practices in
schools, particularly those using a traditional autism lens may explain
why children experience such diculty and why the EDA prole has
garnered so much parent attention. oseractices identied by
researchers and clinicians as helpful in EDA include increasing
certainty (Stuart et al., 2020) or developing ways to manage
uncertainty, increasing demand tolerance, teaching alternative skills
(Grahame et al., 2020), masking demands, promoting interests,
oering choice (Duncan etal., 2011), using agreed upon rewards,
using low demand, avoiding reinforcing avoidance, using low arousal,
picking battles, using indirect language, focusing on non-verbal cues,
managing adult expectations (Eaton and Weaver, 2020), avoiding
head-on confrontation (Fidler and Christie, 2015), using variety,
mystery and novelty, complex language, anxiety reduction strategies,
role-play, visuals to depersonalise demands, providing a safe space,
building self-awareness and self-esteem and having a keyworker
system who is calm and where the relationship is based on trust,
intuition, exibility and adaptability (Christie, 2007). Fidler (2019)
notes an emphasis on whole-school wellbeing is important. O’Nions
and Eaton (2020) identied that in the specic context of completing
an assessment with a child, psychologists benet from being adaptable,
following the child’s lead, inviting the child to help, and including
humour and choice. Interestingly, critics argue that such helpful
practices are not conned to EDA, but instead can beunderstand as
good practice based on current understanding of how to support
neurodivergent individuals (Woods, 2019).
Regarding professional practices that are helpful for families,
authors highlight collaboration (Moh and Magiati, 2012) availability,
empathy, openness to a variety of perspectives (Gore Langton and
Frederickson, 2018) and ability to assess dynamics of relationships
(Green et al., 2018). Despite children experiencing EDA being
involved with many professionals, the most common group of
professionals they are involved with is educational psychologists (Gore
Langton and Frederickson, 2016; Gore Langton and Frederickson,
2018). However, clinical psychologists are also involved in working
with children with EDA, showing support is needed outside of school
(Gore Langton and Frederickson, 2018).
Even though children who systematically avoid demands are in
receipt of psychological support, little literature appears to exist that
explored psychologists’ perspectives or experiences of working with
children with demand avoidance. Doyle and Kenny (2023) found that
psychologists working with this population were keen to access
training and, specically, to learn more about diagnostic practices.
Authors have highlighted gaps in knowledge answerable by future
research, including how to improve wellbeing for children
experiencing EDA (Eaton and Weaver, 2020), whether identication
of EDA is helpful (Truman etal., 2021), how demands might bemade
more tolerable (O’Nions and Eaton, 2020), the developmental
trajectory of EDA and helpful practices (Kildahl etal., 2021; Mols and
Danckaerts, 2021). It seems that those psychologists working closely
with children, schools and families may to contribute to answering
these questions.
is study takes a constructivist approach in exploring
psychologists’ accounts of demand avoidance and extreme demand
avoidance in children. Examining EDA provides a rare opportunity to
explore how psychological constructs evolve from their origin, giving
a voice to psychologists who play a key role in supporting children and
who are well placed to advance our understanding of psychological
phenomena. Acknowledging that the denition of EDA is contested
in the literature, this research holds the a priori standpoint that the
construct of EDA is open to investigation. Similarly, the literature is
unclear on whether EDA is conned to autism (Egan etal., 2020),
thus, this study does not require psychologists to beworking with
autistic children. e present study aimed to address the following
research objectives.
1. To describe how psychologists conceptualise, experience and
approach demand avoidance in children. is objective
informs us about how psychologists have understood and
approached such presentations in the absence of clear guidance.
2. To determine if any of the psychologists’ accounts of demand
avoidance were conceptualised as EDA. is objective helps us
to better understand the utility of the construct of EDA.
3. To explore if there are parallels between psychologists’ accounts
of extreme demand avoidance and the construct of EDA
described in the literature. is objective examines whether
psychologists’ accounts of extreme demand avoidance align
with what is described as EDA in the literature as per Newson
etal. (2003).
ese objectives were addressed using a small-scale qualitative
study of practicing psychologists from the UnitedKingdom, Australia,
and the Republic of Ireland.
Materials and methods
Participants and procedures
A sample size of 10–15 psychologists working with children and
adolescents was anticipated to comply with pragmatic time
constraints, psychologists’ likely interest in being interviewed about

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the niche area of demand avoidance, to create a diversity of
perspectives, and recognising the depth of data likely generated by
psychologists (Braun and Clarke, 2021). Sample size is acknowledged
as a single factor when using reexive TA in a constructivist paradigm.
Data quality was monitored during transcription and following the
12
th
interview, it was deemed there were sucient data to tell a
complex and rich story (Sim etal., 2018).
Table2 gives a summary of participant details grouped to ensure
anonymity. Most psychologists identied as female (n = 9) and a
diversity of ages was achieved. Most psychologists (n = 8) had been
teachers before becoming a psychologist, and others worked in early
years or psychology services. Most psychologists had been trained as
educational psychologists (n = 11). Of the psychologists practising in
Ireland, most were working in one geographical location within
Ireland. ree psychologists were employed by the National
Educational Psychology Service (NEPS), one by the Education and
Training Boards, ve by the Health Service Executive (HSE) Disability
service and, one was in a private service. One practitioner from
Australia and one from the UnitedKingdom also practised privately.
All participants had more than 6 years in practice (n = 12) and most
(n = 11) described their role as senior.
Exemption from a full ethical review was obtained from the UCD
Human Research Ethics Committee on the basis of the research being
on standard professional practice, and research approval was granted
from the Research Advisory Committee of NEPS in June 2022.
Psychologists were recruited via a snowball approach using word of
mouth, social media (Twitter), a Whatsapp networking group of
practicing psychologist across Ireland, and NEPS channels, where a
manager sent an email to a specic geographical area of Ireland. A
leading PDA specic organisation, the PDA Society shared the call for
participants on Twitter. An information sheet detailing the nature of
the research was made available online. All participants were informed
that their anonymity would be respected, and there would be no
identiers (including by service) in the write-up. Participants were
informed that they could withdraw from the study up to 2 weeks
post-interview.
Participants completed informed consent and submitted their
contact details and demographic information (self-identied gender,
level of professional experience, age category, and occupational status)
via a Google form. A pilot test of the semi-structured interview
schedule was conducted with a practicing psychologist in July 2022.
e 12 interviews were conducted by the primary investigator via
Zoom between July and November 2022. Each interview lasted
between 45 and 70 min. Interviews were audio-recorded, transcribed
into Microso Word, de-identied and stored on a secure, encrypted
laptop. Once transcribed, the audio les were destroyed.
Semi-structured interviews
e semi-structured interview schedule was designed based on
the research questions and was adjusted with feedback from
psychology experts and from the pilot study. Table3 describes the
TABLE2 Participants demographic information.
Characteristic Detail Number
Identifying gender Female 9
Male 3
Age Category 30–39 4
40–49 3
50–59 3
60–69 2
Pre-psychology
experience
Primary or post-primary teaching 8
Early years or adult psychology 4
Psychology training Educational 11
Other 1
Years practising 6–10 3
11–15 4
21–25 2
31–35 1
36–40 2
Psychology service Disability 5
School or further education 4
Private 3
Role in organisation Senior 11
Main grade 1
TABLE3 Topics, interview questions, and rationale for inclusion.
Topic Initial question Rationale
Experience with children
presenting with demand
avoidance
Can yourecall a professional experience of working
with a child who avoided demands?
is identies psychologists’ experience of demand avoidance in practice
Psychologists’ conceptualisation
of the presentation
Can youexplain the nature of the demand avoidance
in more detail?
is explores psychologists’ understanding of demand avoidance
Do youfeel this was an example of extreme demand
avoidance?
is explores psychologists’ understanding of what constitutes as extreme
demand avoidance
Psychologists’ approach to
supporting the child
What approaches did youtake supporting the child? Very little is known about how psychologists professionally approach
supporting children presenting in this way
How equipped did youfeel? is explores psychologists’ condence in their work in the context of a lack
of clinical guidance

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interview schedule, detailing each question with the associated
underlying topic and rationale. e interview schedule was designed
using three topics incorporating ve main questions and associated
probes: (a) psychologists’ experience with children presenting with
demand avoidance, (b) psychologists’ conceptualisation of the
presentation and whether the case represented extreme demand
avoidance, and (c) psychologists’ approach to supporting the child.
ere was a degree of exibility within each interview, in that the
order of questions and the time spent exploring each topic were
determined by participants’ contributions, allowing the researcher to
explore issues raised by participants, in line with the constructivist
approach. Initial questions were deliberately broad so as not to
constrain responses, for example, in the approaches section,
participants were asked “What approaches did you draw on in
supporting the child?” followed by probes to gain more information
“can youexplain why youchose those approaches?” and to funnel to
specic topics raised by the participant, e.g., “How was the use of
novelty new for the child’s carers?”
Analysis
Descriptive statistics are presented regarding participants’ self-
identied gender, number of years practicing, role in organisation, and
age category. e semi-structured interviews were analysed using the
six-phase reexive thematic analysis (RTA) approach as outlined by
Braun and Clarke (2019) for identifying, analysing, and reporting
patterns with a dataset. ough sequential phases are identied, the
RTA process is recursive and iterative, requiring the researcher to
move back and forth in a exible way, as necessary. RTA was chosen
as it is exible in approach, and views researcher subjectivity as a
resource, whilst staying close to participants’ own accounts which ts
with the constructivist paradigm informing this study. Identifying
meaning in participants’ responses in RTA is a combination of the
researcher’s judgements of which data answer the research question,
and the importance ascribed to experiences by the participants. While
recurrence of meaning is noted, it is not the focus. e researchers
took a critical orientation to the data, acknowledging that though
meaning was created in the interactions between researcher and
participants, and is inuenced by researcher subjectivity, participants’
accounts of their personal reality remain a valuable means of
understanding their experiences.
Data were transcribed by the rst author into Microso Word
documents and NVivo12 soware (QSR International Pty Ltd, 2018)
was utilised to code and organise data. Transcription was viewed as a
useful part of the familiarisation phase, which also included reviewing
each transcription and noting of items of interest, conicts, initial
ideas, and assumptions (Braun and Clarke, 2019). e research
questions formed the criteria for a rstly deductive approach to coding
material, where the researcher coded the data into three key areas of
experience, conceptualisation, and approach. e predominate
approach for the remainder of the process was inductive, and
prioritised participant meaning, as all interview data were coded
multiple times across dierent key areas to ensure nothing was missed.
Note-taking was used throughout to ensure consistency of approach,
and to track the evolution of codes through various iterations. A
comprehensive approach was taken, meaning many ner grain codes
were created which sought to carry sucient detail to stand alone
from the data (Braun etal., 2016). A mixture of semantic and latent
coding was used, in many cases both, semantic codes reected the
meaning communicated by the participant and latent codes reected
the interpretation of the analyst.
emes were generated from initial codes where the focus was
then on ensuring meaning across the entire data set was reected as
well as how meaning is interpreted to answer the research questions.
Initial codes and themes (phases two and three) were reviewed by the
second author and the corresponding discussion led to further
reection on potential themes in phase four. Discussion did not seek
to achieve consensus but was used as a platform to check assumptions.
A record was kept of several iterations involving codes, subthemes and
themes being removed, revised, and restructured. Original transcripts
were regularly referred to in checking the broader coding context. A
revised thematic map was developed, and some further adjustments
were made, including naming of themes and subthemes. In preparing
for phase six, both authors considered the order in which to report
themes. Data were contextualised in the results section as advocated
for by Clarke and Braun (2013).
Results
Child details
During interview, psychologists were asked to recall their
experiences with one child presenting with demand avoidance.
Children in psychologists’ accounts were typically aged 5 to 9 years
(n = 6) or 12 to 14 years (n = 6), with eight boys and four girls. Most
children were previously identied as neurodivergent (n = 10), with
nine identied as autistic. Whilst accessing the psychologist, four
children were also involved with other allied health professionals,
typically psychiatry (n = 4). Eight children had experienced or were
contemplating an educational placement move, one had experienced
school exclusion. ree were currently in mainstream education, four
in a “special” setting, four in alternative education or were not
accessing any formal education. e following were perceived to
bestrengths of the children described: average cognitive ability (n = 6),
involved in local community (n = 3), seeking social connections
(n = 5), well-developed communication skills (n = 4), and coping with
academic learning (n = 2).
Thematic analysis
ematic analysis yielded six salient themes emerging from
subthemes. e corpus of themes summarised psychologists’
experiences, conceptualisation, and approach in working with
children with demand avoidance (see Figure1). e themes and
subthemes are described in this section, supported by relevant
excerpts from the interviews.
Psychologists’ understanding of child’s
presentation
is theme relates to participants’ accounts of reasons given for
psychologists to become involved with children, oen known as the
referral question. Psychologists noted that reasons given by referrers
were oen removed from a full understanding of the child’s experience.

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References were made to demand avoidance which presented as
externalised emotional responses directed toward self, others, or
material objects. Some psychologists used broad-stroke descriptions,
such as “physical outbursts,” perhaps owing to psychologists receiving
this information second-hand. One psychologist (female) was more
explicit having witnessed a response rst-hand, “he lay on the oor,
rolled himself up in the rug and started kicking to the point where
I was concerned because the walls were glass.” One psychologist
(female) recalled the caring adults felt “targeted” when children “make
comments, about weight, accent and skin colour.”
Disengagement as a feature of demand avoidance was a likely
indicator for psychological involvement, viewed as an internalised
emotional response. One psychologist (female) feared that cases of
internalising demand avoidance were not reaching psychologists as
much as she might expect. Each child described was experiencing
daily demand avoidance, however, the most common reason for
involvement was individuals failing to leave the house. Another
psychologist (female) noted, “he spent a lot of the previous 4 years in
his bedroom.”
e idea that individuals’ regulation went “from 0 to 100” was
another common referral question. Whilst few psychologists had
witnessed this themselves, one (female) who had, recalled the child
“screeching, but the next minute switching into high-
quality conversation.”
Challenges for psychologists
is theme describes three main challenges for psychologists
which include, an ill-dened construct of EDA, working with varying
levels of understanding of the child amongst adults and additional
professionals, and service boundaries which require management.
Participants acknowledge the contested EDA construct has
implications for professional understanding, practice, and
relationships. One psychologist (female) recalled a frustrating
conversation with a colleague who questioned, “aren’t they all demand
avoidant by adolescence?.” One psychologist (female) noted, “I feel
nervous, because it’s not in the DSM, yet something has to exist to
reach the threshold.” Others questioned the value that EDA would
add, with one psychologist (male) describing a risk of, “getting caught
up in the high grass, instead of focusing on the actual practical
implications,” whilst another psychologist (female) added, “what
matters is getting this person out of their bedroom!.” Psychologists
expressed frustration that although a needs-based rather than a
diagnosis-based focus exists in some educational systems, a focus on
diagnostics remains, “on the one hand youdo not need a diagnosis to
get support along the continuum, but, if youhave requested special
treatment, then youneed a reason” (female psychologist).
One expressed concern that with growing awareness, over-
identication of the prole could occur. Many participants disliked
the language used in the construct title and denition, rejecting the
term pathological (a synonym for extreme in the construct title),
based on the medical model of disability. One participant’s experience
was that the construct encouraged them to focus solely on the
language of demands and avoided generating a fuller understanding.
e term manipulative was also problematic because this was not felt
to accurately reect the child’s experience.
Psychologists describe a key challenge relates to families and
schools’ level of understanding of the child’s experience. Many
acknowledge the inuence of parents’ experience of being parented.
One psychologist (female) appreciated her recommendations were
novel for parents, “it was just so unusual initially…encouraging her
FIGURE1
Themes and subthemes.

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14-year-olds to do these things.” Another psychologist (female) noted
parents’ commitment to traditional education pathways impacts upon
progress, “she pushed him beyond what hecould reasonably achieve.”
One psychologist (female) felt the impact of working with parents who
are neurodivergent made aligning goals dicult, “the parent had
challenges with communication and executive functioning, making it
very dicult.”
At school, social and learning expectations, the number of adults
and other children involved were also reported as barriers.
Psychologists explained that cultural norms were sometimes
mismatched with the needs of the child. For example, in relation to a
common school rule in the UK and Ireland regarding uniform, one
psychologist (female) found a uniform rule exasperating, “Why do
youhave to wear a skirt? Just beexible!.” Participants described that
many of the children they met had rst been identied as autistic and
were supported with traditional autism approaches which might not
beuseful, resulting in dicult experiences. Parent and school sta
understanding could be mismatched, oen resulting in blaming
parents. For example, one parent a psychologist (female) worked with,
was told she was “a ridiculous mother seeing problems where there
were none.” is lack of consensus in how to support children with
complex needs contributes to adult exhaustion, which, in turn causes
diculty for psychologists, as it reduces adults’ capacity to build on
psychologists’ work.
e psychologists also encountered challenges with several
professional issues. Psychologists described a lack of control over
many factors within systems in which the children existed. Some
psychologists found it dicult when parent agency meant a poorer
perceived outcome for the child, for example regarding school choice,
“ultimately, Icannot make that call, but it was very dicult holding
that because Iamworried about the long-term implications” (female
psychologist). Not being privy to relevant contextual factors was also
acknowledged: “psychologists operate in an imperfect process, weare
reliant on information relayed to us but that’s subject to the perception
of the narrator” (female psychologist). A further challenge was delay
in accessing the latest research, which caused guilt for some
psychologists, “it’s tough when yousee this young person in distress,
and youthink, weshould have known what was going on” (female
psychologist). Service boundaries involving time was also seen as a
challenge, with many noting this type of work is time consuming.
Others noted being restricted in who they could work with, e.g., not
being allowed to work directly with parents.
Enablers for psychologists
A key sense of togetherness was communicated in relation to
psychologists collaborating with others to bring change for the
children. Shared experience, supervision, and expertise from other
disciplines including occupational therapy, speech and language
therapy and psychiatry, was reported as being valuable. Having follow
up from professionals from other services was useful, owing to
services boundaries. Psychologists referred to a need for both formal
and informal fora, noting, “you need to besitting in a room, here’s a
case study, this is what transpired, these are the approaches” (male
psychologist). Learning alongside colleagues was seen as important,
“we trained together, so we implemented our learning together”
(female psychologist), another described team meetings which
included reecting on “what wescrew up and what weget right”
(female psychologist). Whilst one psychologist noted relying heavily
on academic research, another acknowledged a time barrier, “I do not
have the luxury to belooking through research, I’d love someone to
point me in the direction of something practical” (female
psychologist). Twitter was noted as an ecient method to connect
with the autistic community.
Some psychologists noted the approaches associated with the
EDA construct had been supportive. One stated “I still draw on the
information for when youneed an alternative approach” (female
psychologist), noting the construct can oer an explanation as to why
more traditional strategies have failed. Another psychologist described
using EDA approaches daily. Psychologists welcomed the addition of
the current research, hoping that it would yield practical implications.
Psychologists’ understanding of the child’s
presentation
is theme illustrates the ways in which psychologists
conceptualised the child’s presentation. is theme is connected to the
other theme of psychologists’ reason for involvement, as it describes
how psychologists conceptualise demand avoidance and other
inuencing factors. In addition, this theme includes data pertaining
to psychologists’ descriptions of when demand avoidance is
considered extreme.
Psychologists mainly attribute demand avoidance to autism or
ADHD and anxiety at “exceedingly high” (female psychologist) levels
resulting in autonomic bodily responses. Experience of autistic
trauma, inertia, intolerance of uncertainty, burnout, or a mismatch
between autistic and neurotypical understanding, were all named as
inuential. One psychologist noted that “children who are autistic
have been traumatised numerous times before there is an
understanding of where their autonomic nervous system is at”
(female). Another explained, “demand avoidance might lead
backwards to something that happened which was frightening, and
nobody explained it” (female). Whilst some psychologists felt that
demand avoidance was natural and adaptive, others described it as
resulting from a “complex interweaving of family stu” (male
psychologist) or described it as involving many factors, a “curious
mix” (female psychologist).
Such complexity was reected in the range of challenges
psychologists described children facing at biological, cognitive,
behavioural, aective, and family/school/community levels, with the
latter two appearing most inuential in contributing to the child’s
presentation based on psychologists’ accounts. Aective factors
included negative experiences of expectations (of time, social
encounters and abilities, health, and school), feeling a lack of
physiological safety owing to not being seen or heard “he was at that
top end of the ght or ight, in a really heightened state of anxiety all
the time” (female psychologist), being punished for things outside of
their control, and not having trusted connections, resulting in
emotional responses communicated in a dierent way.
Family, school, and community factors noted by psychologists as
challenges for children included relationship dynamics, as well as
cultural norms about how people experience the world. One
psychologist (female) described family expectations, they had another
child, and they were applying the same rules to her, but wesaid “look,
this is dierent”. Ruptures across key relationships was also reported
as being common.
Psychologists described demand avoidance as extreme when it
was evident from early childhood, occurred in another

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neurodivergence, included externalising, and internalising emotional
responses precipitating harm to others, linked to strong interests in
individuals, appeared as the child having a “denite view” (male
psychologist), evidenced a mismatch between age expectations and
the child’s tolerance, and impacted on the child doing what they
needed or wanted to do.
Psychologists’ focus in supporting the child
is theme describes psychologists’ focus in supporting the
children they described (See Table4) via improving adult practices.
e focus on working with the adults involved with the child rather
than the child themself highlights the truly systemic nature of the
psychologists’ role. Psychologists empower adults by validating their
experience, bringing awareness of assumptions, building
understanding, and supporting them in tuning in to individual need,
whilst considering environmental factors. “Taking a step back” (female
psychologist) from culturally inuenced expectations was referenced.
“Tuning in” (female psychologist) oen involved giving the child a
voice. One psychologist (female) recalled thinking “you [parents]
might know a lot about autism, youmight know a lot about ADHD,
and youobviously know loads about [medical condition] but youdo
not know what it’s like to bethis girl.” Openness to regularly adjusting
the type of support is deemed important, with a psychologist (female)
noting, “I was under no illusions it would belong lasting.” Supporting
children presenting in this way was deemed to be“quite skilled” work
by one psychologist who noted, “I think it is down to subtlety in
approach and it is very, very individualised” (male psychologist).
Success for psychologists
is theme addresses psychologists’ descriptions of success in
their involvement with children. Psychologists communicated that
indicators of success may be small. ey noted that adults’
understanding increasing is a key feature, with one psychologist
(female) describing her involvement as having “shied the parents
thinking about her as deant, to trying to reduce her stress levels.”
Another psychologist (female) noted a parent now “takes steps back
in order to go forward.” Others described increased self-awareness for
parents as important in achieving co-regulation, “she [mother] was
the most regulated she had been ever, and he [child] completely
opened up in a way he’d never done before” (female psychologist).
TABLE4 Practices in supporting the child.
Psychologist’s
Focus
Useful practices for adults
Support adults’ skill
development and coping • Encourage collaboration with other adults
• Increase understanding of child’s perspective, ability, developmental stages, over whelm and anxiety, the autistic perspective, parenting style
• Li age expectations
• Build connections
• Encourage self-care
Encourage a focus on
physiological safety • Increase movement
• Supporting sensory preferences
• Promote emotional safety (increase connections, increase awareness of co-regulation, tune in to emotions; name, validate, give space), in-built
daily emotional regulation (mindfulness, safe spaces)
Encourage matching
ability and demand • Build skills to improve access
• Ensure achievement by taking small steps towards goals
• Be aware of the impact of major transitions
• Match the task to the skill level – do a task analysis and consider reducing demands by increasing supports (dierentiation)
Support regarding
appropriate school choice • Encourage a focus on matching environment to child’s ability to cope with demands including sensory, social, academic
• Get to know all available options incl. Autism classes, special schools, home-schooling, alternative education, and training programmes
Increase awareness of
positively reinforcing
avoidance
• Be aware of access to leisure if there is a lack of functional engagement, e.g., school attendance
Promote increased child
involvement and
autonomy
• Use suggestions and indirect language rather than commands
• View the adult and child as a team working side by side
• Learn about and follow the child’s perspective, preferences, and interests
Promote increased
structure, routine, and
predictability
• Increase predictability via highly consistent and structured use of visuals
• Encourage a present focus by chunking timetable
• Engage in advance planning and thinking
• Provide advance notice of changes and increase support
Encourage regular review
• Be clear about potential short-term impact of support, instead expect changing needs and encourage trial and error, tweaking and renement

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Psychologists also described features of successful change for
children, including relating to other people, seeking others, tolerating
imposed boundaries, or going to necessary places. In relation to
attending therapy appointments, one psychologist (female) noted “she
tolerated me, and she came back,” and another (female) spoke of
increasing ability to tolerate school, “attendance went from 10 min
three times a week, to 90 min every day, massive progress.” A reduction
in signs of child distress was also seen as important.
Discussion
is research aimed to explore practicing psychologists’ accounts of
demand avoidance in children whom they play a large role in supporting
(Gore Langton and Frederickson, 2018). e research sought to explore
how psychologists experience, conceptualise and approach demand
avoidance in children, and, in cases where psychologists conceptualised
the demand avoidance to beextreme, how their descriptions mapped
on to the construct of PDA as originally described by Newson etal.
(2003). Transcripts of semi-structured interviews with 12 psychologists
working with children were analysed using reexive thematic analysis
(Braun and Clarke, 2019). e six themes created provide a rich account
of how this cohort experiences, conceptualises, and approaches demand
avoidance in children. Psychologists appeared to experience demand
avoidance and EDA as a feature of their work. Amidst a lack of clear
clinical guidance, psychologists reported using a range of practices,
overlapping many approaches, in supporting children. e focus was
mostly indirect, emphasising the adults around the child. e features
of demand avoidance described by psychologists as being extreme had
some parallels with those features of EDA described by Newson but also
had key dierences.
Psychologists’ experiences of demand
avoidance in children
Children in need of support
Firstly, psychologists’ descriptions of demand avoidance in
children emphasised their need for support, regardless of their
orientation towards the EDA construct (Woods, 2020). Children’s
need to avoid demands was understood as arising owing to the
dierences between neurotypical individuals and neurodivergent
individuals, which gives rise to complex interactions. Consistent with
Brede etal. (2017) and Doyle and Kenny (2023), challenges were
associated with home and school evidenced by the high prevalence of
school moves and poor health experienced by children and parents.
Such a nding indicates diculty with traditional schooling, which is
likely to have led to negative experiences for families and schools.
Duncan etal. (2011) also refer to the impact of late identication of
such a prole, noting that less helpful approaches may have been used
where a full understanding was lacking. Early support gives children
the opportunity to achieve success.
Common challenges and enablers
Despite controversy surrounding EDA, psychologists did not
experience supporting these children as particularly dierent to other
neurologically divergent groups. One common experience was that of
tensions amongst dierent stakeholders and dierent levels of
understanding. Whilst the department of education model of resource
allocation (Department of Education and Science, 2017) suggests
schools can cater to need without diagnosis, psychologists
communicated that schools still nd it dicult to deviate from the
norm. Doyle and Kenny (2023) also queries the utility of needs-based
models where very novel approaches are needed, such as in
EDA. Insight from young autistic people who had been excluded from
school similarly emphasised the lack of understanding of their needs
as central to their failed school placements. e young people also
cited diculty in understanding how all pupils nding school
challenging could successfully tolerate being placed in the one
classroom. Accounts in the current study also described tensions in
relation to school placement, where psychologists might not see a
placement as a good t for the child. e new progressing disability
service model in children’s disability teams in Ireland also recommends
parent prioritisation of goals (Bradley etal., 2020), which may present
similar diculties for supporting clinicians.
Consistent with previous research, both within the demand
avoidance literature and more broadly within professional psychology
literature, certain factors were seen as enabling success for psychologists.
Psychologists valued learning from peers and from research
disseminated eciently, as has been found elsewhere (Law and Woods,
2018; Hoyne and Cunningham, 2019) as well as through collaboration
with other disciplines (Atkinson etal., 2013; Doyle and Kenny, 2023).
Psychologists in the current study also valued access to neurodivergent
perspectives. Space and time for learning opportunities is likely a
challenge in organisations, but its value cannot beunderstated. Twitter
was acknowledged in the current study as a key avenue to engaging with
neurodivergent individuals. Since NEPS and primary care psychology
are single discipline services in Ireland, it follows that systems may need
to bein place to facilitate multidisciplinary working.
Psychologists’ approach to demand
avoidance in children
Range of (neurodiverse armative) approaches
Despite a lack of guidance about practices for supporting children
with demand avoidance, many psychologists in the current study
approached demand avoidance in a similar way to other psychological
diculties, by focusing on the child’s underlying needs (Astle etal.,
2022), and by building understanding for all involved (Milton, 2018).
Psychologists emphasised the individualised nature of this work which
draws on a strengths-based approach to diversity, consistent with
previous ndings (Wilding and Griey, 2015; Doyle and Kenny, 2023).
Clinical guidance produced by National Institute for Health and Care
Excellence (2013) emphasises the individual nature of support in the
case of autistic children and the PDA Society (2022) in the case of
autistic children with an EDA prole. In supporting children,
psychologists drew upon a range of approaches including relational,
with a focus on adult self-regulation (Cunningham, 2022), anxiety-
based, as advocated for by White etal. (2022) and, neurodiversity-
informed, as suggested by autistic children themselves (Goodall,
2018). EDA adults (Johnson and Saunderson, 2023) and autistic
young people experiencing demand avoidance (Brede etal., 2017) also
referenced the role of the relationship with trusted adults around them
in emotional regulation and the role of uncertainty and change in
anxiety. Approaches associated with EDA were also in use, argued by

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Woods (2019) to represent good practice in supporting neurodivergent
children. Behavourist methods described in other studies (e.g., Law
and Woods, 2018) were not oen mentioned in the current study,
perhaps owing to a move towards neurodiverse armative approaches
identied by psychologists as becoming increasingly relevant to their
work. Using a range of approaches makes sense for psychologists as,
regardless of their psychological challenges, children’s minds and
histories are diverse (Allsopp etal., 2019).
Indirect work
In approaching demand avoidance in children indirectly,
increasing adult understanding and managing expectations were seen
by the psychologists as being important, in line with previous ndings
(Law and Woods, 2018; Hoyne and Cunningham, 2019; Eaton and
Weaver, 2020) and clinical guidance (National Institute for Health and
Care Excellence, 2013; PDA Society, 2022). Christie’s (2007) guidelines
placed strong emphasis on the signicant support needs of the adults
working around a child presenting as demand avoidant. In addressing
adults’ own anxiety, psychologists encouraged them to value diversity
and to move away from a within-child decit model inuenced by
psychocentrism (Gruson-Wood, 2016) and developmentalism
(Gabriel, 2021), common in education, towards viewing diculties as
occurring relationally.
Developmentalism results in demand avoidance being
misinterpreted as pathological, as it deviates from what is expected for
children according to age (Moore, 2020). Adults’ experience of being
parented and of education were also seen as inuencing their
expectations, in line with Kerr and Capaldi (2019) and Hornby and
Blackwell (2018). Indirect work with parents and teachers means the
quality of the relationship matters (Hoyne and Cunningham, 2019).
In the context of demand avoidance, parents value good listening,
care, no judgement, and openness (Gore Langton and Frederickson,
2018). e Department of Education model for resource allocation
(Department of Education and Science, 2007) and the Progressing
Disability Service (PDS) model for children’s teams (Bradley etal.,
2020) in Ireland both rely on empowering the adults in a child’s life.
Psychologists also described encouraging adults to regularly
review their practice, noting that this may bedicult as needs change
and develop over time. Previous authors have suggested continuity in
access to psychologists might be helpful (Gore Langton and
Frederickson, 2018; Doyle and Kenny, 2023), with support increasing
and decreasing as needed (Green etal., 2022). In theory, both in
children’s disability teams and in NEPS, children can achieve recurring
support, although this is of course dependent on the limited
availability of psychologists.
Psychologists conceptualisation of
demand avoidance in children
Demand avoidance in autism
Despite its original categorisation as pathological demand avoidance,
and the lack of consensus regarding demand avoidance as occurring
within autism, psychologists have typically observed demand avoidance
in autistic individuals. Demand avoidance as occurring solely within
autism has been strongly campaigned for (e.g., PDA Society UK). A
strong recognition factor described by families upon receipt of the
diagnosis and approaches described as diering from those used for other
autistic people are being cited as evidence for the existence of a sub-type.
Eaton and Weaver (2020) highlight the central feature of EDA appears to
be anxiety, which is itself not a diagnostic feature of autism. Woods
(2022a,b,c) suggests that there are power dierences at play, with the
potential for the autism industry to create an EDA product that would
allow private practitioners to gain nancially by oering a contested
diagnosis. High levels of support for EDA may betherefore explained by
social identity theory which describes disabled people needing to create
in-groups to protect against ableism (Bogart and Dunn, 2019). In the
current study, psychologists’ acceptance of demand avoidance as
occurring mainly in autism shows the power of mass interest and suggests
that care must betaken regarding the social inuence on constructs of
disability (Woods, 2022a). Woods (2023, p. 48) describes how a
“premature communities of practice” can form as a result of campaigning
on social media, in this case relating to EDA as occurring soley
within autism.
Taking a broad perspective
Psychologists viewed children’s presentations broadly, as complex,
and as occurring because of a range of factors, and not solely associated
with demand avoidance. Features included high levels of distress, and
documented impact on health of children and adults, replicating
ndings of Brede etal. (2017), Gore Langton and Frederickson (2018),
and Doyle and Kenny (2023). In line with previous ndings (e.g., Doyle
and Kenny, 2023), psychologists attributed dierences to known features
of neurodivergent individuals. Some psychologists used the language of
neuroscience, describing autonomic bodily stress responses which
happen in the context of imposed demands. is may also align with
the Royal College of Psychiatrists (2020) who highlight avoidance of
demands is a common feature of humans, in a brief note on PDA in
their guidance on the psychiatric support of autistic adults. Adults
experiencing EDA in the study by Johnson and Saunderson (2023) also
reference the role of the autonomic nervous system in explaining their
bodily responses, though some discussed being motivated by stress
which perhaps suggests a role of volition. Stress response explanations
are consistent with models described by Green etal. (2018) and Woods
(2022b) which take the view that stress is transactional with the
environment and occurs when demands exceed coping ability.
Transactional models have implications for environments such as
homes and schools in which children exist. Given the high level of stress
exhibited by children in the current study and previous research, it
seems that demands placed on some children do not appear to match
their coping ability.
Extreme demand avoidance as a construct
Parallels with Newson
All psychologists in this study described the children they worked
with as experiencing extreme levels of demand avoidance. Much of
what is known about demand avoidance is based on Newson etal.’s
(2003) early criteria for EDA. Parallels exist between Newson’s criteria
and the criteria described by the psychologists in the current study,
but key dierences also emerged. Importantly, social manipulation
was not discussed by the psychologists, although it is a central feature
of Newson’s descriptions. In addition, the psychologists described the
impact on what children want or need to do as being important, which
showed respect for the individual, rejecting a developmentalist
perspective (Moore, 2020). Contrastingly, Newson etal. (2003) focus
on children not carrying out actions as desired by adults. In addition,

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Newson does not refer to the transactional context where demands
exceed coping ability. Whilst Newson included developmental
features, e.g., language delays, other authors had removed them
(O’Nions etal., 2016) and one psychologist saw emergence in early
development as important in delineating EDA from demand
avoidance. Other features described by Newson which achieved little
or no coverage by psychologists in this study include passive early
history, comfort in role play and, so neurological signs.
Utility of the construct
ough the psychologists in the current study reported using a
range of approaches to work with children with demand avoidance,
representing good practice for neurodivergent individuals (Woods,
2019), most rejected the medicalised language and utility of the EDA
construct. Rejection of medicalised language is reected in the variety
of terminology available to describe EDA and has been identied
previously amongst psychologists (Raskin et al., 2022). Few
psychologsists were open to including the prole as part of an autism
identication and had previously done, consistent with suggestions by
the PDA Society UK in their 2022 guidance. Most psychologists focused
on children’s underlying needs, which may be in line with a
transdiagnostic approach as described by Astle etal. (2022). is
approach recognises that some characteristics in children’s proles
occur outside of categories, giving the example of autism and anxiety. A
transdiagnostic model focuses on characteristics, over diagnostic label,
and is in line with Doyle and Kenny (2023) who suggest noting the
presentation of anxiety and demand avoidance in formulation.
Guidelines from the Royal College of Psychiatrists (2020) relating to
autistic adults also advocate for managing underlying factors such as
severe anxiety. Even advocates of PDA question the utility of diagnostic
classications and note that dierent proles can present with similar
features (Duncan et al., 2011). In a foreword to a book from the
perspective of an 11-year-old girl with PDA written by Duncan etal.
(2011), a leading clinical psychologist in the eld, Judy Gould, notes that
its content is likely to be of use to individuals “not conforming to
conventional social rules, who are oppositional, or just dierent” (Fidler
and Christie, 2015, p.10). Rather than adhere strictly to a categorical
approach, a transdiagnostic model may beof value as it allows for early
identication of strengths and vulnerability, potentially reducing
inequality in accessing support, as children do not have to wait for
characteristics to besuciently problematic to reach a threshold.
Limitations
ere are several limitations of this research, meaning that
caution must beused when interpreting ndings. Firstly, because the
research set out to test the EDA contrast, it purposefully did not work
with a precise denition of what is meant by demand avoidance. e
implication of this means wecannot say if the practices pertain
specically to demand avoidance, or if they are useful practices for
children in general or in a specic category. Similarly, wecannot say
whether the practices psychologists identify as useful in supporting
children will work at higher or lower levels of demand avoidance than
what is described. A detailed account of children’s proles or
experiences was not possible meaning any possible intersectionality
is not addressed. Information such as age of child is missing which
may berelevant to ability to learn coping strategies as alluded to by
Johnson and Saunderson (2023).
In addition, by its design, the study relied solely on the views of
psychologists. is is particularly relevant when considering practices
described to be useful or the indicators of success, as psychologists’
perceptions may dier from that of teachers, parents, and children whose
perspectives would give the most reliable account. Psychologists’ views
are likely highly inuenced by the inherent privilege associated with their
role (Stoudt etal., 2012). Since the neurodiversity paradigm has shown
so clearly in its emphasis on the subjective voice, means of achieving
feedback from teachers, children and families in relation to the usefulness
of psychologists’ support would beworthwhile.
In relation to the limitations associated with the recruitment
method, though Twitter and a Whatsapp group were used, it is worth
noting that such platforms cannot reach on all potential psychologists
thus restricting participation from the outset. In addition, the lack of
consensus and keen interest surrounding the topic of EDA, and related
varying diagnostic practices means that recruitment may have relied
on those with a particular view or agenda in relation to the construct
coming forward or being invited by colleagues to participate – thus
biasing the study. is is particularly the case where recruitment was
shared within the network of the PDA Society who present as very
committed to a set outlook on the construct. In addition, although the
recruitment method was designed to recruit non-Irish based
psychologists, most participants who agreed to beinterviewed were
working in one geographical location in Ireland. is possibly resulted
in a restricted overview of practice as there may have been local
arrangements in place to address the lack of formal guidance in
relation to assessment for and support of demand avoidance. Owing
to the limited geographical spread, social desirability in interview
responses may have also been a factor, particularly given the similar
training orientation of the lead researcher and participating
psychologists, use of alternative data collection methods, e.g.,
questionnaire for future researchers may mitigate this risk.
A further consideration is that it was not possible to present a
detailed analysis of the relationships between multiple codes, given the
length limitations of this manuscript. In addition, though
psychologists’ accounts of EDA are compared with the construct as
outlined by Newson etal. (2003), the current analysis was conducted
thematically, and psychologists were not asked to list their criteria
specically. us, it is likely that psychologists’ full understanding as
to what constitutes EDA may not have been obtained. Finally, 11
psychologists described autistic children, this may have been because
they saw the study as associated with the known construct of EDA,
which has come to beattributed to autism, or because their most
prominent experience of demand avoidance is in children who happen
to beautistic. In my view, despite these limitations, this exploratory
study which aimed to explore psychologists’ accounts of their
experiences of, conceptualisation and approach to demand avoidance
advances understanding of the EDA construct, makes important
research to practice links, and highlights implications for practice and
policy of psychologists working with children.
Conclusion
Little is known about how psychologists’ experience, conceptualise
and approach children’s demand avoidance, nor about how they
conceptualise extreme demand avoidance (EDA) in their work. e
current study gives voice to psychologists in relation to the practices
they draw upon and the utility of the construct of EDA as rst

Haire et al. 10.3389/feduc.2023.1230014
Frontiers in Education 12 frontiersin.org
described by Newson. ough psychologists used EDA aligned
approaches, they rejected the medicalised language and utility of the
construct. Such a nding is timely given the growing impact the
neurodiversity paradigm is having on psychologists’ work. Instead,
psychologists focused on the current characteristics and needs of the
child, an approach which could allow early identication of strengths
and vulnerability, thus reducing inequality in accessing support.
Psychologists drew upon a range of approaches in working
systemically with the adults in children’s lives, shiing the focus to
transactional contexts, and to valuing diversity. It is evident that owing
to of their emphasis on systemic work, psychologists are well placed
to incorporate neurodiversity into practice.
Data availability statement
e raw data supporting the conclusions of this article will
bemade available by the authors, without undue reservation.
Ethics statement
Written informed consent was obtained from the individual(s) for
the publication of any potentially identiable images or data included
in this article.
Author contributions
LH: conceptualisation, data curation, formal analysis,
investigation, methodology, project administration, writing – original
dra, and writing – review and editing. JeS: conceptualisation,
methodology, supervision, and writing – review and editing. JoS:
conceptualisation, methodology, and supervision. UP:
conceptualisation and supervision. All authors contributed to the
article and approved the submitted version.
Conflict of interest
e authors declare that the research was conducted in the
absence of any commercial or nancial relationships that could
beconstrued as a potential conict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors and
do not necessarily represent those of their aliated organizations, or
those of the publisher, the editors and the reviewers. Any product that
may be evaluated in this article, or claim that may be made by its
manufacturer, is not guaranteed or endorsed by the publisher.
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