By Jasmine Murphy, Fiona Andrews and Maria Morgan

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©Flavio Coelho/Moment/Getty Images Plus

Introduction

This aim of this neurodiversity-informed dentistry series is to promote a more accessible and inclusive culture where neurodivergence is understood, accepted, and destigmatised for the benefit of neurominority patients, students, and staff. This third article, released within Disability Pride Month [July], seeks to raise awareness of the models of disability and provides suggested accommodations that can be considered for neuro-inclusion by the dental team. Such adjustments could improve patient access and experience, thereby improving oral health and reducing inequalities. If you are joining this series for the first time, please visit article one for a general introduction to neurodiversity [https://go.nature.com/3rnmcdU], and article two which explains how executive functioning, sensory processing and oral health literacy differences may impact on the oral health status of neurominority patients [https://go.nature.com/3O7JBsx]. Further articles in the series will also cover neuro-inclusion in the workplace and educational settings.

Neurodiversity is short for neurological diversity. It refers to the biological fact that brains are unique and have many different ways in how they process information and interact with environments. Neurominorities tend to behave, think, feel, process, and interpret information in ways that differ to most other people.

Medical and social models of disability

Disability is a complicated thing.

The medical model asks:

'What is wrong with the individual, and how do we fix them to allow them to access services and participate?'

The medical model focuses on a person's impairment as the cause of disability and then looks at how to 'fix' these individuals in order to correct their difficulties. In essence, the model looks at what is 'wrong' with the person and not what they need. This medicalisation of disability has been criticised as it implies that such individuals can never be equal. As it also loses sight of what individuals need, this can lead to the provision of segregated services which may not be appropriate.

The social model asks:

'What is wrong with the service and how do we fix the barriers to accessibility and inclusion for this individual?'

The social model takes a different stance and suggests that a person is not disabled by their condition, impairment, or difference but the barriers, attitudes and structures of society which don't allow them to 'fit' is the disabling factor. This model focuses on promoting support systems that allow individuals who are impaired or different to live their lives as they are by removing barriers and creating inclusive and accessible spaces for all.

While physical, sensory, intellectual, neurological, or psychological variations may cause individual functional limitation or impairments, these do not have to lead to disability unless there is failure to account for a person's individual differences.

The social model rejects the notion that an individual must be 'normal' to enjoy the full range of human experiences. This means that while physical, sensory, intellectual, neurological, or psychological variations may cause individual functional limitation or impairments, these do not have to lead to disability unless there is failure to account for a person's individual differences.

The identification and removal of such barriers creates equality.

The Equality Act 2010

The Equality Act 2010 is applicable in England, Scotland and Wales. It protects those receiving care or education as well as staff from being treated unfairly because of any characteristics that are protected under the legislation.1 Under the Act, no individual should be discriminated against in service provision, employment, or education. The Act provides a legal definition of disability: 'a physical or mental impairment which has a substantial and long-term adverse effect on a person's ability to carry out normal day-to-day activities'. Many neurominorities may in fact not identify as 'disabled' but they are, importantly, still protected by law. It is important to note that, according to the Act, there is no need for a diagnosis, it is the effect, not the cause that matters and healthcare settings are still required to make reasonable adjustments to enable everyone to gain equal access. This is hugely important because neurominorities can face substantial health inequalities, are less likely to be satisfied with the healthcare they receive, or to understand and be understood by health professionals. Barriers that prevent people from accessing care or thriving in workplaces or educational settings must be removed as failure to do so is unlawful discrimination.

Brief recap from article 2

The daily lives of neurominority patients can be impacted through differences in their executive functioning (EF) and/or sensory processing (SP) which can affect their oral health.

EF and SP differences can affect lifestyle choices such as diet selection, tobacco, alcohol and substance use, self-care such as undertaking oral hygiene, attending dental appointments as well as receiving dental instructions or treatment.

Differences in both EF and SP can also affect oral health literacy (OHL) if information is not communicated in a manner, method, or format that the patient can process and understand. This hinders their ability in accessing dental services and making appropriate decisions about their oral health.

By applying the social model, it is the barriers imposed by dental services that are disabling neurominority patients. Such obstacles may include but are not limited to:

  • Communication, procedures, and the environment which do not take EF and SP differences into account

  • Attitudes and perceptions around neurodiversity due to lack of awareness and understanding.

Reasonable adjustment considerations

Dental settings are required by law to make reasonable adjustments to accommodate neurominority patients. This requires a holistic approach to patient care by considering their overall health, their psychological and social needs, their long-term oral health needs, and their desired outcomes (Standard 1.4 - GDC Standards2). All patients should be provided with an opportunity to disclose their neurodiversity when completing their medical history forms.

If a patient has disclosed their neurodiversity, never make any assumptions about their needs or preferences - ask them what they need and what will work for them.

Reasonable adjustments should be tailored to the patient's specific needs and preferences. Family members or carers (with consent) can also be involved in this process as they can provide valuable information about the patient's needs, preferences and communication methods which support the patient's overall well-being. Some considerations are shown in Table 1.

Table 1 Adjustments that could be made to support a patient's needs and preferences
Full size table

Neurodiversity-friendly oral health resources available

Brush DJ (https://www.brushdj.com/) is a free multi-award-winning App that is suitable for use by all ages. It:

  • Plays two minutes of music to encourage effective brushing

  • Works with either manual or electric toothbrushes

  • Allows reminders to be set (changing toothbrush, brushing at least twice a day, flossing, using a mouth rinse at a different time to toothbrushing, visiting a dentist)

  • Provides visual aids with short, animated videos on how to carry out basic oral hygiene tasks

  • The oral health information reflects the evidence-based guidance Delivering better oral health.

Brush my teeth (https://go.nature.com/3rshVWl) is an accessible and inclusive oral hygiene resource for those who find brushing their teeth a challenge. They promote co-development and independent brushing. It provides videos and suggestions tailored to which level of support the person feels they need.

Health boards and trusts across the UK are beginning to develop their own resources to support dental patients. One such collaboration is NEST (https://go.nature.com/3DrvmJf), a Neurodiversity Empowerment and Strategy Team linking with the dental teams to not only provide information but work with dental facilities in creating neuro-inclusive spaces.

Creating neuro-inclusive dental spaces

Every human has a distinct sensory composition to process and manage stimuli from their surrounding environment. Because every brain is wired in its own unique way, everyone interprets and experiences their environments differently. Hypersensitive people prefer environments with controlled stimuli and dislike those with excessive stimuli such as bright lights, noise, unfamiliar scents, too many textures and colours or temperature fluctuations. On the contrary, hyposensitive people prefer more sensory stimuli. By taking purposeful measures, dental settings can ensure that their environment reflects the diverse ways people experience the dental environment which enables their accessibility.

Educating the dental team on neurodiversity promotes awareness and understanding of different sensory sensitivities...

The dental team can use the free Neurodiversity friendly environment tool (https://go.nature.com/3JRKwLi), the BBC Neurodiversity and Building Checklist19 (https://go.nature.com/44GhWo0) and Sensory Friendly Resource Pack (https://go.nature.com/3XNm2bF) to:

  • Raise their awareness of the challenges that can be experienced from the physical environment

  • Identify problem areas that have been overlooked

  • Plan simple changes to the dental care environment that can make it more accessible for neurominorities.

Designing and accommodating for neurodivergence19 (https://go.nature.com/44GmdYy) and disability doesn't just benefit neurominorities - it helps everyone, just as designing for people who are deaf can actually support hearing people too20 (https://go.nature.com/3rn99ci). With neuro-inclusive dental environments, neurominority patients do not have to change who they are to fit the setting.

Benefits of creating neuro-inclusive dental settings

  1. 1.

    Improved patient experience: By implementing accommodations and understanding the unique needs of neurominority patients, dental teams can create a more positive and comfortable experience for them. This could also reduce missed dental appointments.

  2. 2.

    Enhanced communication skills: Working with neurominority patients requires the dental team to develop effective communication strategies. This can enhance communication skills, such as the ability to explain procedures in a clear and concise manner, the use of visual aids and adapting communication methods to suit individual patient needs. These skills can be valuable when interacting with all patients, including those without neurodiverse conditions.

  3. 3.

    Support informed decision making and consent: Educating the dental team on neurodiversity promotes awareness and understanding of different sensory sensitivities, communication styles and behavioural patterns. This knowledge allows the team to approach patient care with empathy, respect, and sensitivity, fostering a more inclusive and supportive environment for all patients. Such an appreciation of neurodiversity will support informed decision making as well as consent for dental treatment and care.

  4. 4.

    Professional growth and development: By developing skills in providing care for neurominority patients, the dental team can expand their professional competencies and enhance job satisfaction.

  5. 5.

    Positive reputation: When dental settings demonstrate a commitment to inclusivity and accommodate neurominority patients, they are more likely to earn a positive reputation within the community.

  6. 6.

    Compliance with legal and ethical considerations:

    • Making reasonable adjustments for neurominority patients aligns with the requirements of the Equality Act (2010)

    • Neurodiversity training for the dental team is aligned with The Health and Care Act (2022)21 as well as the Care Quality Commission's requirements in England.22 In Scotland, dental teams will be required to comply with the Learning Disability, Autism and Neurodiversity Bill.23 In Wales, dental teams are required to comply with the Social Services and Well-being (Wales) Act 201424

    • Accommodating neurominority patients is aligned with the GDC Standards with ethical considerations, promoting fairness, dignity, and respect for individuals with diverse needs

    • Adhering to these regulations and standards ensures that dental settings provide equal access and non-discriminatory care to all patients.

Conclusion

It is important to recognise that every neurominority is unique and no assumptions should be made about their needs or preferences. A holistic approach to patient care is critical to the delivery of successful outcomes and experiences for neurominority patients. Dental settings can adopt a social model of disability by creating neuro-inclusive practices into their structure and procedures. This means that fewer individual reasonable adjustments will be needed over time, and where adjustments are needed, the dental team can be much more responsive to individual needs.

A holistic approach to patient care is critical to the delivery of successful outcomes and experiences.

All members of the dental team should receive appropriate training and education on neurodiversity covering awareness, communication strategies, as well as understanding sensory sensitivities and techniques for supporting patients' unique needs. Overall, accommodating neurominority patients not only benefits the patients themselves but also contributes to the professional growth, reputation, and ethical practices of the dental team. By fostering a welcoming and inclusive environment, dental practices can provide equality of access to dental care and improve overall patient outcomes. Open communication should be encouraged, and feedback actively sought from neurominority patients, parents, carers as well as staff to continuously refine and adapt the neuro-inclusive practices in the dental setting.

Next in this series

Communication is paramount and needs to be tailored to each patient's needs. The next article will cover oral health literacy as well as digital accessibility as part of neuro-inclusion in dental settings.