For over a decade, I’ve helped neurodivergent individuals get the reasonable adjustments they need in exams, schools and workplaces. But recently I found myself asking: what do ‘reasonable adjustments’ look like during a visit to the dentist?
Sitting happily in my dentist’s chair with my eyes closed, as he pre-narrated every detail of the procedure to me while my fingers and feet jiggled away, I wondered just how unpleasant this experience would be without the adjustments he had made for me.
I hadn’t visited a dentist in over five years (I’m an ADHD procrastination virtuoso!) and I had never had a filling before. Despite the previous consultation a couple of weeks before, I continued to pace about in the waiting room as I was not exactly sure what to expect. Would it be agonisingly painful? Would there be blinding lights and unusual textures and smells?
My dentist is clearly used to reassuring nervous patients, as he made every effort to calm my nerves and ensure that I was comfortable. He also made me aware that I could ask him to stop by grunting if I felt any pain or discomfort.
Reassured, I opened wide, as everything seemed fine. However, just three long seconds later my ADHD thought-cacophony had asked me several hundred questions about what to expect and issued a few dozen warnings about the sounds, smells, sensations and vibrations I may be about to be surprised by. I knew I needed some things other patients might not, and I knew it was ok to ask for them. So, I did.
However, it is not always this straightforward. Many neurodivergent individuals experience an intense desire to please others, even at their own expense. They don’t want to be considered inconvenient, or perceived as silly, dramatic or weird. Often, they would rather endure significant discomfort, than risk putting themselves out there to experience rejection or dismissal. This is known as rejection sensitivity disorder (RSD), a term coined by ADHD expert William Dodson. This is when the brain responds similarly to emotional pain as it would to physical pain. Individuals with ADHD can experience emotions with heightened intensity and it may hurt a neurodivergent individual more to try and fail to be understood, than to suffer in silence.
It is therefore important to consider what adjustments can be made to accommodate a neurodivergent patient.
These could include:
Pre-narration: Knowing that the dentist would tell me each step of what he was about to do, just before doing it, including advance warning of each new tool, substance or procedure, meant I could quiet down the threatscanning, predicting part of my brain that had gone into overdrive.
Why? The ADHD brain likes to be busy. If there’s nothing to be busy with, it often ruminates, frequently with a negative bias. When the body is still, the brain may ‘entertain’ itself by catastrophising or threat-scanning. Attempting to make predictions may be a learned strategy to get ahead of sensory sensitivities. A ‘pre-narration’ throughout the procedure may reassure the brain, reducing the impulse to threat-scan. The same may benefit patients with anxiety, OCD, trauma and PTSD.
Introducing a timeline: Knowing how long things were going to take, including updates on how long it had been so far and how close to a break I was, made it possible to remain calm.
Why? Many neurodivergent individuals experience time differently due to brain differences. Once you’ve told a patient something will take 10 minutes, and just three have passed, they may have no real sense of whether they are nearly done, or not.
Regular breaks and movement: Being able to get out of the chair and ‘shake it out’ meant I could return to the chair for the next filling without the buildup of an internal pressure that being still generates within me. Knowing my dentist would offer this as soon as it was next possible (and keep me aware of the passing of time) really helped.
Why? ADHD brains have structural and chemical differences. They process dopamine differently, for example. This results in a need for stimulation, often manifesting as physical restlessness.
Movement breaks mean your ADHD patient does not have to endure unnecessarily long periods of uncomfortable stillness. Reassuring a patient they can fidget while you work allows them access to an invaluable ‘pressure release valve’. Patients with OCD or sensory processing difficulties and autistic patients may also need to ‘stim’ to help them process sensory information and to self-soothe in a stressful situation. ‘Stimming’, short for self-stimulatory behaviour, can be both physical and verbal; it’s unique to each person. Welcoming and accommodating this need can reduce stress for the individual.
Avoid a sensory overload: The one thing that took me by surprise when I was in the dental chair was an unusual smell. My dentist informed me he was going to use a different, grittier paste. I was prepared for the texture but not for the smell! It had a potent scent that made me feel sick, panicky and overly alert. I had to forcefully hold myself still against the urge to wrench my head away from it. If something you need to use has an unexpected taste, texture or flavour, letting your patient know this is a possibility and offering a break before/after exposure may help. Also, if you have alternative flavour options, introducing choice may also be useful.
Why? Many neurodivergent individuals experience heightened sensory sensitivity. They often take in every little detail, including things many would not even notice. Often there is no hierarchy to incoming sensory information; everything seems equally important. Trying to process everything, while attempting to choose what to focus on and direct attention to accordingly, can be exhausting and overwhelming.
What some perceive as a subtle smell, a perfectly tolerable noise, a comfortable level of lighting, a mildly unusual texture or taste, can feel unbearable – sometimes even akin to painful – for those with sensory sensitivities.
Be curious and acknowledge without judgement: Asking open questions can give a patient the confidence to share something that you may not have anticipated. For example, asking, ‘Is there anything you’re curious or anxious about before we start?’ Additionally, if you notice something that seems to make a patient uncomfortable, you could acknowledge this without judgement. This could be as simple as saying, ‘I think I noticed you tense up when we turned on the suction, is that right?’ The patient’s response may help you understand their experience and better place you to offer the necessary support.
Why? Factors like RSD, people-pleasing, embarrassment or lack of self-awareness or self-advocacy skills may prevent patients seeking, or accepting (when offered as implicitly ‘unusual’ or ‘extra’) accommodations. We can remove the feeling of ‘unusual’ (RSD hears and feels this as weird) and ‘extra’ (RSD hears and feels this as inconvenient) if we reframe the question from ‘How do we know which patients have which conditions, and therefore who we need to offer which accommodations to?’, to ‘How many opportunities can we build in to welcome and normalise neurodivergent needs in our routine behaviours and practices, in ways that include everyone?’
Every patient is different, and this list of examples is by no means exhaustive. So how can you integrate meeting the needs of neurodivergent patients into your practice, particularly when some patients may not feel confident enough to ask for them?