‘The more we understand ourselves, the more we can break down stigma’: In light of ADHD awareness month this October, Dr Fiez Mughal offers 10 facts about adult ADHD and dentistry.
Simone Biles. Mel B. Michael Phelps. Lily Allen. Emma Watson. Russell Brand. Me.
What do we all have in common? The same as many of you reading this: attention deficit hyperactivity disorder.
Yes, ADHD. I was blessed this January with my diagnosis, turning 42 later that month.
Shockingly as many as two thirds of ADHD adults worldwide are undiagnosed.
As a dentist, I want to share information about ADHD amongst the recent media surge of this disability, and to celebrate its strengths.
What is ADHD?
ADHD is a mental health condition that is defined through analysis of behaviour (according to www.adhduk.co.uk).
There is a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with day-to-day functioning and/or development.
Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) states that children must show six or more symptoms over multiple settings, in both patterns of the disorder, for over six months.
For adults, it’s five or more symptoms.
The National Institute for Health and Care Excellence (NICE) states that the UK incidence is 5% in childhood and 3-4% in adults (according to www.nice.org.uk).
Children are diagnosed by a psychiatrist, a paediatrician or a qualified ADHD healthcare professional.
Causes
- Multiple genes (80% aetiology)
- Environmental – sociodemographic determinants, but much research on subtler influences too
- Gender – boys > girls, with a ratio of 4:1. The problem of undiagnosed adults is linked to misleadings of this ratio, which will be discussed later
- Brain – ‘neurotransmitter pathways’ abnormalities. These are caused by developmental differences across multiple cortical regions, in size and activity. They affect a range of neurological networks, resulting in atypical behaviours fundamental to ADHD, but presenting in different ways – as ‘strengths’ and ‘weaknesses’.
History
As was the sentiment towards the then un-named condition since the 1700s, in 1902 paediatrician Dr George Still published an article in the Lancet on a ‘Disorder of Moral Control’.
The later 20th century saw increased research, but also highlighted conflicting theories defining this misunderstood condition.
Approaching the 1990s, the UK and the US finally diagnosed ‘ADHD’.
It wasn’t until 2008 that DSM-V proved that this childhood disorder, if undiagnosed, never goes away.
The impact of this can be terrifying, but also fascinating.
During the 1990s, only severe cases were diagnosed – historically the ‘naughty boys’. This incorrect term continued the stereotype.
Undiagnosed adults
It is this stereotype that resulted in thousands of ‘lost’ children, surprisingly only now being diagnosed as adults.
The challenge is ‘symptoms’ versus ‘impairment’. Children can have ADHD, but present differently.
Until primary school, I was the textbook example of an ADHD boy, eg climbing out the cot as a one-year old, dangling out my bedroom window when I was two, running off and getting lost when I was three.
But due to a combination of my parents’ discipline (or perhaps exhaustion) and rare-as-UFO sightings of some intelligence (eg becoming a member of Mensa at 14), my ADHD was ‘masked’.
Gender leads this ‘masking’ debate, on why some children present differently – the ratio of adults diagnosed with ADHD in women vs men is almost the reverse of the childhood 4:1.
Dentists are an important part of this discussion – do ADHD girls behave differently to ADHD boys at the dentist?
I believe there is scope for dentists to play a key role in helping recognise children and adults with ADHD and other aspects of mental health.
Failings in primary health care
Neurodiversity has waited too long to make the headlines it rightfully deserves today.
That is, variations in the human brain and the different experiences perceived by such an individual, but which are equally valid as those from neurotypical individuals.
All mental health experts agree on this: ADHD is over-diagnosed in the US but under-diagnosed in the UK.
For over 40 years the US has led the world in ADHD research. Thanks to them, a great deal is known about ADHD now – yet professionals themselves still have a problem.
A close source from charity ‘ADHD-UK’ cites that a female GP diagnosed in her 30s didn’t tell her medical practice and other staff. This is the stigma of ADHD.
Prior to my diagnosis, a similar healthcare professional happily dismissed my claims, whenever mentioned socially.
‘These attitudes have held the UK back’, says Dr Tony Lloyd, CEO of the ADHD Foundation.
GPs do a tremendous amount of work and do it very well. Understandably they do not have time to be experts on rarely taught subjects at medical school, but arrogance mustn’t cause them to reject a patient’s right to be referred.
Shockingly, the NHS waiting list is as long as two years. I paid privately for my diagnosis having been rejected before.
Suicide has tragically been the result of when people also feel they have no-one who can help them.
ADHD and oral health
Some misconceptions have also affected dental patients, and of course many may be ‘masked’. Therefore, as dentists we are unaware.
Routines like daily tooth-brushing may be difficult.
In addition, ‘dopamine shortages’ may increase addictions, like caries-causing sugar.
Useful tips for supporting patients with ADHD include:
- Simplify oral health messages you give
- Send more reminders for appointments
- Allow extra chair time for those with poor time keeping.
Undiagnosed patients
Co-factors (other aspects of neurodiversity) often exist, such as dyslexia, anxiety, depression, OCD, autism spectrum, Tourette syndrome and bipolar disorder.
The necessity of ADHD awareness is astounding because these are often secondary conditions, in other words, people needlessly suffer with these conditions or are even wrongly diagnosed, purely because ADHD is missed as the primary diagnosis.
A case study reports a 21-year-old female with mood swings and concentration difficulties, presenting to the dentist with awake bruxism.
A diagnosis of ADHD and commencement of medication for anxiety and ADHD instantly stopped her bruxism, and even her need to wear a bite-guard.
Intersectionality, as always, is at the heart of recognising ADHD and other aspects of neurodiversity, eg intelligence, gender, sexuality, race, parental influence, and teachers.
Undiagnosed dentists
‘Masking’ and the nuances of intersectionality are also why many professionals don’t realise they have ADHD.
This was the experience of myself, and also Catriona McVey who was diagnosed at 20.
She recently wrote for the British Medical Association (BMA), recognising that medical education does not empower such medical students like herself.
My own experience at an esteemed postgraduate surgical college resulted in that diploma having only a 25% pass rate in total. Regardless of ADHD, such dental institutions must ensure robust and accountable teaching is always prioritised over elitism.
But ADHD is also a strength, as shown by Dawn Brown MD. She was diagnosed during her 30s – black, female, and a powerhouse of an ADHD advocate – and runs the ADHD Wellness Centre.
In fact, if we look at neurodiversity and think back to our university lecturers and other professionals, many of us have a ‘penny drop’ moment upon suddenly realising those that taught us are included too.
Management of ADHD
At dental school, symptoms of ADHD might arise as distractibility, impulsivity, organisation, time management, workflow and productivity. ‘Executive function’ is a key issue with ADHD.
I would over-compensate by studying instead of socialising. But at other times my ‘hyperfocus’ – an ADHD trait – saved me.
Ryan Orwig, a trail-blazing learning specialist, gives some useful tips for those at university with ADHD.
ADHD coaching is very popular and something that I have started this year.
Medication is also beneficial. The stigma around this is completely understandable, but we must refuse to give air-time to those espousing cries of ‘conspiracy theory’ if they have not read evidence-based literature.
Stimulants given to those with ADHD actually increase clarity and focus rather than cause hyperactivity.
Also, five types of medicine are licensed in the UK. They are the most effective and fastest-acting for any condition in psychiatry, but not without side-effects.
How can I know more?
Dr Flowrence Mowlem states: ‘It is a public health concern if individuals with ADHD are being missed and not gaining access to services and treatment that they could benefit from’.
Please see these links below for more help.
If like me you were initially rejected by your GP, they may not be aware of an official ‘ADHD screener’ survey, also available online. This is for any patient to complete.
If you score above a particular threshold, your doctor most refer you. And if they refuse, they need re-educating.
The more we understand ourselves, the more we can break down stigma.
Let’s challenge stereotypes and fight against society ‘putting us in a box’ – it’s time to celebrate our unique superpowers!
The ADHD-UK global conference kicks off this Thursday (6 October). Find out more here: adhduk.co.uk/global-conference.
References
American Psychiatric Association (2022) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
McVey C (2021) Becoming a doctor with ADHD. British Medical Association
Monuteaux MC, Faraone SV, Herzig K, Navsaria N, Biedermann J (2005) ADHD and Dyscalulia: Evidence for Independent Familial Transmission. Journal of Learning Disabilities 38:86-93
Orwig R (2021) What You Need To Know About ADHD in Medical School. STATMedLearning
Rubia K (2018) Cognitive Neuroscience of Attention Deficit Hyperactivity Disorder (ADHD) and its Clinical Translation. Front Hum Neurosci.12:100
Still GF (1902) Some abnormal psychical conditions in children: the Goulstonian lectures. Lancet 1008-1012
Tecco JM, Tecco S (2020) Awake Bruxism Treated with Pregabaline in a Patient with Generalized Anxiety Disorder. Psychiatria Danubina 32:33-35.
Follow Dentistry.co.uk on Instagram to keep up with all the latest dental news and trends.
