By Jasmine Murphy, Fiona Andrews and Maria Morgan

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©Annaspoka/iStock/Getty Images Plus

Introduction

The term neurodiversity describes the idea that people experience and interact with the world in many different ways. Neurodiversity does not imply any specific diagnosis, although some of the more common diagnoses associated with neurodiversity include autism, ADHD, dyslexia, dyspraxia, dyscalculia, and tic disorders1 (see part 1, https://go.nature.com/3rnmcdU). While differences in thinking, learning and/or behaving may pose a spectrum of challenges to functioning in a largely ‘neurotypical' society, they're not innately disabling and can be important strengths. It is wise to recognise that such differences complement each other, offering a richer and fuller perspective on life.

Although the neurodiversity movement2 has gained mainstream traction, dentistry has been slow to acknowledge or accommodate neurodiversity within the profession. Despite the increasing focus on diversity, equity and inclusion in the dental workforce, neurodivergent colleagues are frequently overlooked with value in diversity conversations being placed on gender, race, ethnicity, religion, sexual orientation, or socioeconomic status.

The exact numbers of neurodivergent colleagues working in all areas of dentistry is unknown. However, it should be noted that with growing awareness of neurodiversity, there has been increased recognition of neurodiversity in medical student cohorts3,4 which will undoubtedly be mirrored in dental student cohorts, and also across the whole of the dental profession. As dentistry is still working to increase representation for many aspects of diversity within the profession, we should also be mindful to represent diverse minds.

Although there are many challenges, struggles and barriers being faced by our neurodivergent colleagues, the aim of this article is to focus on celebrating neurodiversity strengths. The following article will discuss prejudice and difficulties experienced.

Myth and stereotype busting

Here are some myths which need to be tackled around neurodiversity and dentistry. For further myths and facts on neurodiversity, please see part 1 of the series1 (https://go.nature.com/3rnmcdU).

Myth: Neurominority people cannot enter or succeed in dentistry.

Fact: Neurodivergent colleagues can be successful in all areas of dentistry. Our profession in fact selects for neurodiversity strengths such as focus, attention to detail, perfectionism, creative thinking, problem solving, pattern recognition and empathy, all of which are valuable traits in dentistry. The profession can also benefit from the ability of an autistic or ADHD person to hyper-fixate or hyperfocus on a particular topic which can culminate in a high degree of expertise. Generally, dentistry is procedure-based and solution-focussed, which is attractive to innovative but concrete thinkers and therefore offers a good lifestyle choice for a neurominority individual.

Myth: Neurominority colleagues are poor communicators and therefore provide poor patient care.

Fact: There's often misplaced concern about the ability of neurodivergent colleagues in being able to connect and empathise with patients. Communication with patients is relatively structured and task focused, which is ideal for some neurodivergent colleagues. With increased attention to detail and ‘bottom-up' style of thinking (using details to form concepts, which is generally the opposite way to the majority neurotypical ‘top-down' thinking approach),5,6,7 some neurominority colleagues are able to explain things well by breaking concepts down into bitesize chunks which are easily understood by patients. Furthermore, as some neurominority colleagues may take things literally, they can provide clear, honest and straightforward communication as they don't tend to use ambiguous language. Neurominority colleagues can also have an advantage in bringing their lived experience with increased understanding and empathy to patients.

Myth: ‘High functioning' neurominority dental colleagues aren't technically neurodivergent.

Fact: One common term neurodivergent people often hear is ‘high functioning' - usually, to describe someone with a neurodevelopmental condition who, for the most part, appears ‘normal' and not seemingly greatly impaired by their condition.8,9,10 These individuals may be charismatic, appear to communicate well, seemingly succeeding academically or professionally. However, the issue with this label is that it overlooks the struggles these neurodivergent individuals face and can result in them receiving little help or flexibility from their colleagues, employers or education and training establishments. Many are against this term because it tries to redefine these individuals as ‘normal enough'.11 Just because an individual may perform well academically, communicate well or succeed professionally, it doesn't mean they don't need more time to process information or have specific needs which require support. Unfortunately, successful neurodivergent adults who are considered high functioning still report higher levels of negative judgements from their peers.12,13

We all sit at different places on the cognitive spectrum, meaning that the way we think, behave and process information is unique to us.

Myth: Neurodivergent dental colleagues are all similar.

Fact: This is not true - we all sit at different places on the cognitive spectrum, meaning that the way we think, behave and process information is unique to us. However, neurodivergent individuals often have thought processes which are more unique than most people. Therefore, the skills and barriers neurodivergent colleagues face in the profession are unique to them. A neurodevelopmental diagnostic label does not mean that all individuals have the same talents or experience the same challenges as each other.

The strengths of diverse minds

It has become common to view neurodevelopmental conditions such as autism, ADHD or dyslexia using a deficit model. Such a model, which focuses almost exclusively on impairments and limitations, ultimately leads us to see neurodivergent individuals as broken people who need to be fixed14 (read more about medical and social models of disability in part 3 https://go.nature.com/44OBCWM). The neurodiversity movement challenges us to rethink this through the lens of human diversity.15 As opposed to only focusing on impairments, the neurodiversity movement sees neurominority individuals as possessing a complex combination of cognitive strengths and challenges. For example, difficulties in understanding social nuances, filtering competing sensory stimuli, and planning the tasks of daily living may be coupled with strengths in detailed thinking, memory, and complex pattern analysis.15 Neurodivergent people can also have more creative insight in comparison to their neurotypical peers. For example, neurodivergent colleagues may have different approaches to problem solving and this could be more effective than a neurotypical colleague's solution. A diverse dental workforce would also help us better reflect and serve our patients as those with lived experience of neurodivergence can better appreciate the patient perspective. Figure 1 provides some examples of neurodiversity strengths that are beneficial to dentistry.

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Examples of some neurodiversity strengths that are beneficial to dentistry

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Why create neuro-inclusive educational and clinical dental settings?

There are many reasons why an inclusive and diverse dental workforce is something to strive for. We all have different skills and experiences that can enrich the profession. A wide variety of skills can promote optimal success across an organisation and indeed, in our profession. Employment, education and training settings can ensure that the unique talents of our neurodivergent colleagues are supported, developed and nurtured.

Personal stories of neurodiversity strengths from dental colleagues

Abigail Craven NEBDN(Cert Oral Health Education), NVQ(Dip Dental Nursing), BSc(Hons) Dental Hygiene and Dental Therapy

Dental hygienist and dental therapist

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Abigail

‘My name is Abigail; I come from a dental nursing background and have recently graduated as a mature student from the University of Leeds. I am now working as a dental hygienist and dental therapist. I am autistic and ADHD (although this isn't proper grammar, language is important here for me - I say ‘I am' because my neurotype is an integral part of my identity which cannot be separated from any part of myself). I have a lot of the common traits of these neurotypes which I experience as unique strengths as well as difficulties.

I love working in dentistry because of its foundations in evidence-based science, which forms clear reasons for every action. Due to my logical and analytical brain, having delineated guidelines and procedures allows me to perform my job to a high standard. During my time as a dental nurse, I developed a ‘special interest' in dentistry which fuelled my thirst for knowledge and determination to become a dental therapist. This intense passion goes hand in hand with my ability to ‘hyperfocus' on tasks related to my special interest, where I can experience a flow state of complete absorption. My pattern recognition capabilities help me put together pieces of the jigsaw such as clinical presentation with patient histories, to recognise patients' individual needs and tailor the appropriate advice. Other strengths relating to my neurotype include outside-of-the-box thinking, high attention to detail, and a keen ability to detect errors. Thanks to the culture in the University of Leeds School of Dentistry and the support I received, I was able to harness these strengths to graduate with a Class I, and I even achieved my goal of winning all of the academic awards out of my cohort.

I am optimistic that celebrating our differences and presenting the opportunity to be understood will help to prevent harmful stereotypes about neurodivergent people, remove employment barriers and allow our unique skills to flourish in the field of dentistry. My hope is that people will meet me in the middle with curiosity, and without judgement.'

Ben Marriott NEBDN(Dip Dental Nursing), DipHe(Dental Hygiene), BSc(Hons) Biochemistry

Dental hygienist

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Ben

‘I'm a newly qualified neurodivergent dental hygienist. Although I felt I was behind everyone else in my cohort and having to play catch-up all the time, I managed to complete the course and gained the top overall marks in my year group. A lot of neurodivergent people can do extremely well academically, but it is often not without personal cost. I tend to have an inability to start something due to fears around perfectionism, but once I start, I can knock out a top-class essay in record speed. I have started working as a dental hygienist and my perfectionism is in many ways an asset as I continuously strive to make sure everything is watertight, from my conversations with my patients to my clinical note keeping. With awareness and support, and a few small adjustments at work, it is highly likely that neurodivergent people like me will be some of the best clinicians in the profession.'

Fiez Mughal BDS, MFDS RCS(Eng)

General dental practitioner with Special Interest in Implant Dentistry

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Fiez

‘“Inconsistently consistent” summed up my abilities in a nutshell, during a moment of self-reflection from the noughties, puzzled by the nature of my haphazard competence throughout life. Such moments are often precursors that evolve into discovering ADHD, as with me. And as with other undiagnosed neurodivergent adults, the knowledge and understanding of ADHD was also in its infancy while those adults were children, with experts at the time only focusing on extremely obvious symptoms in the severest of cases. The same experts have now realised why the majority of such adults ‘slipped through the net' during school - ADHD is not a ‘one-size-fits-all' presentation, with different strengths as well as weaknesses.

Strengths that have helped me as a dentist include ‘hyperfocus' - from being the first in my school year to get offers from the maximum number of medical/dental schools, to the attention required in specialist implant surgery and their restorations, this trait is a superpower for me when my ADHD is stimulated. High ‘empathy' is why I and many others who are neurodivergent are privileged in being able to help phobic patients overcome their fears. I feel humbled when parents have remarked over the years that I'm the first dentist their autistic children are happy to see (maybe the children connected with my as yet unknown neurodivergence). And the ‘sense of justice' that compel many of us is perhaps the strongest trait (eg, openly challenging inequalities in society). It is perhaps why I am so passionate about raising awareness of neurodiversity in our profession, to help destigmatise a fundamental part of humanity, across all professions. Such neglect has sadly robbed society of many lives and robbed many lives of fulfilment. If being a dentist who is not ashamed about having ADHD can help stop anyone else suffering, it is absolutely worth risking any bias I (hope not to) face.'

‘Robert' (not real name) RN(Adult)Dip NS, BDS, MFDS RCS(Eng), DDPH RCS(Eng), MPH, GDL, BPTC

General dental practitioner and barrister

‘I received my neurodiversity diagnosis later in life and had already completed undergraduate and postgraduate degrees. My diagnosis was initially a shock however as time went on, it explained why I was generally better at science subjects and why I entered into a practical vocation.

The greatest strength and pure joy of being neurodivergent is the ability to think outside the box which has frequently been fed-back to me. Some examples here are in undertaking “hybrid treatment plans”, the ability to visualise and re-arrange a room of furniture, to problem solve and think of different solutions. My condition has made me a very competent proofreader as I have had to focus on every single word, sentence construction and punctuation. These skills have been invaluable as they have allowed me to also pursue my interest in law and I was recently called to the bar. The best advice I was given and will pass on, is to enjoy being neurodivergent - it's literally a gift!'

Jasmine Murphy BDS(Hons), MSt(Camb), MRes(Manc), MFGDP(UK), MFDS RCS(Edin), MFDS RCS(Eng), FDS(DPH) RCS(Eng), FFPH RCP(UK)

Retired Consultant in Dental Public Health

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Jasmine

‘Hi, I am Jasmine and have recently retired as a Consultant in Dental Public Health. People who meet me can find me intelligent, friendly, funny and relatively “normal”. I say this because this is what made early identification of my neurodiversity so difficult as I subconsciously worked hard at keeping my neurodiversity traits hidden (to myself and others). Because of this, I only received my neurodiversity diagnosis towards the end of my dental career. As neurodiversity can be quite hard to understand, talk is usually focused on all of the negative traits associated with it but the neurodivergent brain is wildly wonderful and needs to be celebrated, too.

My neurodiversity leads me to thrive in an environment that demands creative thinking. My ability to harness my inherent hyperfocus and high energy supports me in being able to deliver at pace. My nervous system is rarely at rest and my mind is running at all times - this helps me to find innovative solutions. My attention is never ‘deficit' - it is always excessive - it's not a lack of interest that makes it hard for me to process information, but my brain's desire to absorb so much of it all at once. Rather than being an obstacle to learning, my neurodiversity makes my brain crave stimulation and input. When learning new things (especially if it interests me), my brain automatically looks to connect and ponder that new information with what I already know. I also have a unique aptitude for spotting patterns in learning and practice, seeing links between ideas and concepts, whilst moving between the abstract and pragmatic.

I am also a compassionate person; always rooting for the underdog - hence choosing to specialise in public health, constantly seeking to reduce inequalities in health outcomes and advocating for health justice specifically for marginalised, disadvantaged, stigmatised and underserved population groups. My emotions are deep and intense and I am often too empathetic. I have a great deal of tenacity and am somewhat a perfectionist. Whatever I do, I attack it whole-heartedly. For me, there is no such thing as a quick project or doing something by halves (even if I want to) and I will often deep dive into things, whilst also keeping sight of the bigger picture. Essentially, my neurodiversity has made me the sensitive, hardworking, enquiring, philosophical, deep thinking, open minded, creative and determined dental specialist that I have become.'

Self-managed workarounds by neurodivergent dental colleagues

‘Fitting in is about assessing a situation and becoming who you need to be to be accepted. Belonging, on the other hand, doesn't require us to change who we are; it requires us to be who we are.' (Brown, 2018)16

Most dental settings are designed to suit the majority of the population who are neurotypical. Intended or otherwise, such practices can create barriers and challenges, making it difficult for neurominority individuals to thrive which can lead to discrimination17 and inequalities.18 Although it may appear that many neurominority dental colleagues are practising successfully (at least on the surface), many could also be seriously struggling in silence due to stigma and a fear of lack of understanding from colleagues, educators and employers. It's important that we are aware that being neurodivergent can be a very different experience for each person. Neurodivergent people often know what their strengths and weaknesses are, which is built from a lifetime of creating workarounds to allow them to succeed.

Talking and sharing lived experiences is helpful in normalising subjects that have traditionally been off limits. Here, we have created a safe space for some neurodivergent colleagues to share their lived experiences of some of their work-arounds due to their neurodiversity challenges. Quite a lot of energy goes into compensating for neurodiversity characteristics which would actually be much better spent developing effective scaffolding strategies and nurturing their strengths instead. Although it is appreciated that everyone conceals their weaknesses to a certain extent, neurodivergent individuals employ and perform an inexhaustible number of compensatory strategies.

Abigail, dental hygienist and therapist

‘Due to challenges with my working memory and executive function, I have often forgotten appointments, plans, deadlines etc. I process written information a lot better, and when I have written things down on my wall planners, it not only prompts me of my upcoming arrangements, but also reduces my cognitive load.'

‘Having fun with drama and learning about social interaction through the perspectives of different characters really helped me build neurotypical-style social and communication skills which does not come naturally to me. This art of character-playing has facilitated my ability to “mask” so that I can make good first impressions and get by in surface-level interactions. As I have gotten older, I have learnt that sometimes it is appropriate to mask, but ultimately it is exhausting, and is a huge injustice to my authentic self.'

Ben, dental hygienist

‘I am very aware of my personal challenges around organisation and time management, so I overcompensate in many ways. This involves arriving at work an hour early and not going home until I have prepped all my clinical notes, checked medical histories and radiographs and completed initial templates for the following day. This eases pressure on myself, allows for a smooth workflow and for any issues that I need to research beforehand to be achieved in good time.'

‘During my final year of studies, I self-advocated for one of my supervisors to have a weekly catch-up with me where I was able to set my own targets and have some external accountability for completing them.'

Fiez, general dental practitioner

‘“Masking” affects all areas of life, eg education, socialising, work. Following diagnosis (January 2022 for me), powerful revelations are akin to a spiritual awakening, from looking back at my life and suddenly seeing my neurodivergent self, and also when realising how early in life I started masking. Socially, I don't see much masking... am I a born social leader? Far from it, it was just too much effort to understand! No-one wants to be seen as socially lacking, but I decided during school it's easier to be unpopular than not be true to myself. Obviously that still hurts when you're a child, sometimes now too, but on the flipside it meant my social connections are more authentic and uniquely eclectic too (and actually another ‘hallmark' of neurodiversity - beyond well-documented social differences/difficulties, individuals tend to score higher in authenticity than neurotypicals).'

‘During my thirties, home chores and life admin became incomprehensibly overwhelming, until one weekend I asked a friend who was relaxing at his home if he would be OK relaxing at mine instead, desperate after the procrastination was impacting my dental duties too. While he watched hours of telly, I finally rattled through all my chores before getting us dinner, acknowledging that it was odd for his company to help while we were in different rooms. Fast forward to my forties, I learnt such company is actually a recommended technique to improve efficiency, called “body-doubling”.'

‘At work, though naturally a “night owl”, in recent years I have started the daily habit of waking up before sunrise. The impact on the stresses of NHS primary care are almost immediate. The sense of calm arriving at work when sometimes still dark was a new experience, impossible to maintain on days with a “conveyer belt” of patients, but to get admin out of the way before people arrive helps reduce chaos throughout the day. I didn't know that both body doubling and such time management techniques are common ADHD coping mechanisms; to learn after getting diagnosed the similarities such people share, made me feel a deeper connection with my condition.'

Robert, general dental practitioner and barrister

‘My late diagnosis in life has meant that to some extent, I have developed a series of coping mechanisms to compensate for my executive function challenges with my “leaking working memory”. These have been refined over the years to help with the clinical side of dentistry. Examples are using both tooth notations (UR6 and 16) to be certain, checking and re-checking treatment plans and clinical notes.'

‘Taking dental/pain histories in a formulaic manner helps me to ensure that nothing is missed and I can recall what has been said to me.'

‘I tend to take my own notes at practice meetings and will normally check them with the practice manager or practice owner to make sure that I have understood everything.'

Jasmine Murphy, retired Consultant in Dental Public Health

‘Although I graduated with honours and distinction in clinical dentistry, and have successfully completed specialty training, I have felt consistent and continuous pressure to “mask” or compensate for my differences that favour neurotypical behaviour in order to succeed. Some people incorrectly think the ability to mask is a good thing, as it makes me appear “normal”. This is wrong. Although I have been masking all my life and the mask has fused into my skin, masking is a high-energy expenditure with personal consequences. Such interaction is cognitive not intuitive, and the intense effort required to maintain it is not sustainable indefinitely.'

‘As I struggle to estimate time due to difficulties with my executive function, I over-compensate by meeting all deadlines ahead of time (sometimes a month before!) and arriving early for meetings (if I am on time or a few minutes late, my anxiety levels are through the roof!)'

‘I compensate for my difficulty in making eye contact with people by looking at a person's nose or their mouth when they are speaking.'

‘I find it difficult to understand indirect, ambiguous language littered with metaphors, sarcasm and veiled messages. I have found studying how people behave and communicate in films and books helpful in reducing misunderstandings as nuances of neurotypical norms seem opaque and sometimes bewildering to me.'

What is the difference between masking and compensating?

Masking, camouflaging, blending in, compensating, impression management; everyone, neurodivergent or otherwise, does this to a certain extent. However, the stakes are higher, and the task is more difficult for neurominority people as it requires cognitive effort, concentration and learning.

Masking and compensation, although frequently used interchangeably, are two different processes. Masking consists of a combination of camouflaging and compensation techniques. Although masking is a compensatory behaviour, it's the process of changing, hiding, suppressing or concealing one's authentic self in order to ‘fit in' and connect with others, or perhaps more specifically in order to be perceived as neurotypical and to avoid the prejudice and judgement that comes with being ‘different'.19,20,21,22,23 This can include suppressing stimming (soothing repetitive behaviours) or intense interests, forcing eye contact or talking less than one would like to in order not to stand out. It is suggested that masking is more often used by females.20,24,25,26,27,28 Masking is also different to the adjustments neurotypical people make in response to social cues where they may moderate behaviour to enhance social success. The short- and long-term consequences of masking include stress, exhaustion, challenging stereotypes and threats to self-perception.29,30,31,32,33,34,35,36

Compensatory strategies differ slightly from masking as it involves finding ways to actively compensate for neurodivergent difficulties37,38 compared to masking where neurodivergent behaviours are hidden or stopped.39 It is an adaptive process whereby new behaviours are generated in order to avoid negative outcomes. Cognitively, this might be similar to a dyslexic person finding a different way to learn to read40,41 or battling procrastination with ‘body doubling'.42 Compensatory strategies that are employed to help to approximate the skills of those perceived as ‘normal'43 by hiding the effort needed to get something done require effortful processing.44 Such strategies can aim to strengthen things like memory, attention, and problem-solving skills and revolve around ‘energy demanding' and time consuming efforts to control and circumvent neurodivergent tendencies.45 Overworking is a common compensatory strategy for some neurodivergent people which can also unfortunately lead to stress and burn-out in the longer term.46 In addition to excessive fatigue, other harmful effects of masking include not receiving appropriate support and delayed diagnosis and treatment.

Neurominority colleagues can engage in masking or compensatory strategies independently or employ both processes (Fig. 2). When both masking and compensatory techniques are utilised together, this significantly increases the likelihood of anxiety, depression, exhaustion, burn-out and loss of identity.34,47,48

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Some common ways that neurodivergent colleagues can engage in maskingcompensatory strategies

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Neuro-inclusion in dentistry

Neurodivergent dental colleagues want the same things as everyone else: opportunities for career advancement, job satisfaction, personal and professional growth. Stigma, a lack of awareness and lack of appropriate infrastructure can cause exclusion of people with neurodevelopmental differences. Rather than attempting to change our neurodivergent dental colleagues to make them fit in, we need to be supporting them to be the best they can be. Neurodiversity can be an advantage when our colleagues are in the right environment and supported in making use of their strengths, instead of constantly trying to overcome challenges. To achieve this, neuro-inclusion in dentistry is essential in order to reduce disabling factors and amplify diverse abilities.

As neurominority dental colleagues constitute a significant hidden minority within dentistry, fostering an inclusive environment is vital, as it enables breaking down of stereotypes and embracing diversity. It is time to openly welcome neurodiversity as part of the range of human diversity in dentistry, not only to meet statutory duties on equality, or objectives on diversity and inclusion, but because dentistry needs and benefits from all kinds of minds.

Diversity in Dentistry Action Group (DDAG)

Advocacy and allyship are important in the pursuit of inclusion. The Diversity in Dentistry Action Group (DDAG) was formed with the view to understand, acknowledge and educate on the presence of discriminatory problems faced within the dental professional by ethnic minorities and of women, highlighting under-representation of these individuals and significant disparities.49 They extend their support here for the inclusion of neurodiversity in the dental profession:

‘The dental world is a composite of diverse minds. Amongst these minds lies natural variation in human neurocognition. Pivoting from simply acknowledging neurodiversity to neuro-inclusion is a significant first step towards supporting our colleagues in being able to feel more comfortable in being their authentic selves, overcome barriers and harness their unique talents, which in turn can help improve the provision of high quality, safe patient care.

The DDAG supports initiatives that promote neuro-inclusion, aligned to the key DDAG principles of change for proactive inclusivity within the profession.

Whilst a shift in societal understanding and awareness of neurodiversity has paved the way for positive change, the dental profession has yet to adopt this culture, and this work has started the conversation on how best to support the aspiration of valuing and embracing neurodiverse colleagues within our profession.' -DDAG

Conclusion

An approach to neuro-inclusion in dentistry where all colleagues' strengths and talents are recognised and emphasised, while also providing support for differences and needs, will help to make dentistry a more inclusive profession, allowing all members of the dental team to thrive.

Next in the series: HOW educational and clinical dental settings can be neuro-inclusive

The benefits of taking a neurodiversity-informed approach in dentistry should now be apparent. Not only is supporting neurodiversity the right thing to do, but it also leads to greater diversity of experiences, ideas, and perspectives. Unfortunately, this has rarely been the case. The challenges are magnified without support, many burn out and are leaving the medical profession prematurely.50 The recurrent narrative particularly among late-diagnosed individuals in the medical profession is one of personal distress, career difficulties and often a truncated career.51 Some personal stories of challenges, difficulties and prejudice faced by neurominority dental colleagues shall be shared in the next article. Change of career or early retirement are common, yet with increased understanding and recognition of the needs of our neurominority colleagues, many of these difficulties are remediable and timely support (which are often inexpensive and easy to provide) could lead to increased retention of highly skilled colleagues.

When it comes to neuro-inclusivity, it's important to remember that any changes and adjustments which can be made aren't exclusively beneficial to neurodivergent colleagues. In fact, many changes are also incredibly beneficial to the whole team, whether they're neurodivergent or not.