By Jasmine Murphy, Fiona Andrews and Maria Morgan

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©mattjeacock/iStock/Getty Images Plus

Introduction

The purpose of this series is to champion a more accessible and inclusive culture where neurodivergence is not only understood but accepted and destigmatised, benefitting neurodivergent patients, students, and staff. Recognising neurodiversity as a biological fact acknowledges the diverse ways individuals experience and interact with the world. While we've highlighted conditions like dyslexia, dysgraphia, dyspraxia, dyscalculia, ADHD, ASC, and Tic Disorders in these articles, it's crucial to note that this list is not exhaustive.1 Additionally, many neurodivergent individuals may have more than one of these conditions.2

Furthermore, neurodiversity brings unique strengths to the table. The varied cognitive processes associated with neurodivergent conditions often contribute to enhanced creativity, adaptability, and innovative thinking. These positive attributes, when acknowledged and embraced, not only enrich the neurodivergent individual's experience but also contribute positively to team dynamics and problem-solving (for further reading, see Part 5: https://go.nature.com/3uk2Jw5).

Effective communication is essential, with language playing a pivotal role. Preferences for terminology describing neurodivergent individuals can vary. Identity-first language places emphasis on a person's identity within the context of a neurodevelopmental condition (eg, ‘I am an autistic, ADHD, or dyslexic person'), while person-first language prioritises the individual (eg, ‘I am a person with autism, ADHD, or dyslexia'). Ultimately, what matters most is respecting individuals' preferences in how they wish to be referred to. Asking about someone's preferences not only creates a safe and inclusive space but also demonstrates a tangible act of allyship, promoting comfort and understanding.3

This article adopts a social model of disability approach (see part 3: https://go.nature.com/44OBCWM ),4 which frames disability as a result of environmental and attitudinal factors rather than an individual's health condition or impairment.5 This is in contrast to the traditional medical approach where the individual's impairment is viewed as the primary cause of their problems and something to be ‘fixed' or ‘normalised'. According to the social model, an individual is not seen as ‘having a disability' but rather as ‘being disabled by physical and attitudinal barriers'. The focus should therefore centre on removing these disabling barriers. Promoting inclusive and supportive environments can encourage open communication and an inclusive culture of respect for neurodiversity.

Intersectionality

Neurodiversity is not limited to individuals of a specific gender, colour, age, or ethnicity; instead, it is commonly intersectional in nature. Intersectionality recognises that everyone is part of multiple social identities (such as race, gender, sexuality, faith, culture) that intersect and interact, resulting in distinct and intricate experiences of advantage or disadvantage. For instance, an individual belonging to multiple minority or under-represented groups, such as being transgender, neurodivergent, of Muslim faith, from a disadvantaged social background, and of Chinese descent, is likely to face compounded challenges compared to those faced by an individual from a single minority group. Embracing intersectionality allows us to understand how an individual's many minority identities contribute to their experience of exclusion and isolation.

Intersectional discrimination can significantly increase unfairness (see part 4: https://go.nature.com/3PHzzPQ )6 within the dental profession. It can affect career development, progression, academic achievement, and being exposed to unfair disciplinary processes.7,8 Addressing each aspect of diversity in isolation is not enough, as it risks overlooking our more excluded and isolated colleagues who belong to multiple under-represented identity groups. We should recognise and understand how these various identities intersect, forming complex layers that contribute to greater unfairness (Fig. 1).

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Intersectionality

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Personal stories from colleagues

Jasmine Murphy, Retired Consultant in Dental Public Health

‘My neurodiversity is not just a part of who I am; it's an essential aspect of my identity. It forms the core of my personal and professional existence and I consider it a vital aspect of my intersectionality along with various parts of self that define me. As a person of colour, shaped by the heritage of parents from different ethnic minority groups, and having originated from a middle-income country, my life's story is rich with layers that shape my experience of the world. These identities naturally enrich the unique lens through which I view the world. Navigating the complexities of my intersectionality adds depth to the challenge of uncovering whether the barriers I have encountered are due to my heritage, race, gender, age, or neurodivergence.'

Fiez Mughal, General Dental Practitioner with Special Interest in Implant Dentistry:

‘Discovering you have ADHD can be upsetting for some, and a revelation for others, “seeing” the world for the first time, seeing “yourself” for the first time. What struck me (from my ADHD diagnosis) was realising a sudden advantage I had, also related to my intersectionality but from decades ago, with a parallel sense of dynamic. I am English, Muslim, and gay. I was proud to say this over 20 years ago also, but it was a lot more traumatic. Hearing fears now from many adults diagnosed as neurodivergent, mirrored my own fears coming out as gay (and Muslim) - it's a journey I have travelled before, and I believe showing vulnerability is a strength when being authentic. So, to anyone feeling scared to “come out” as ADHD, don't be, any pain you may feel is part of your healing. Society is a better place when we don't wait for others to change it for us. And never underestimate the power of sharing your story. Someone somewhere, maybe thousands of miles away, is stronger thanks to you!'

Ben Marriott, Dental Hygienist:

‘Having only come to the realisation of my neurodivergence in my late thirties, I can now look back and see how many difficult situations in my life have been underpinned by it. I have experienced compounded forms of discrimination in my life, including in the dental workplace due to my multiple social identities. As a transgender man I was told it was inappropriate for me to work with patients, use the pronouns I wanted, to grow facial hair and so much more, and have lost jobs due to this direct discrimination. I've also been discriminated against due to my disabilities, having been told that I shouldn't be working with patients because my stoma bag would smell, for instance.'

Stigma

Stigma, a lack of awareness, and inadequate infrastructure, including dental practice policies and educational approaches, can unintentionally contribute to the exclusion of neurodivergent individuals. Despite being unintentional, this leads to discrimination by denying them equal access and opportunities. Neurodivergent colleagues face a substantial challenge when deciding whether to disclose their diagnosis, grappling with internalised stigma (driven by professional norms) and the potential for subsequent prejudice and discrimination. This hesitation often results in a sense of isolation, making it challenging for colleagues to seek support and understanding from peers, employers, and educators. An editorial in the British Journal of General Practice underscores that many neurodivergent doctors choose to remain undercover due to the pervasive fear of discrimination.9 Their challenges at work typically revolve around fitting into the workplace culture or organisational hierarchy, rather than issues related to patient care. There is no reason to assume that this feeling would be any different for our neurodivergent dental colleagues.

Prejudice and discrimination

An example of prejudice and discriminatory practice can arise when a neurodivergent individual is instructed to ‘pay better attention', ‘stop fidgeting', ‘make eye contact', ‘write better notes' or ‘spell more accurately'. This is ableist language and is similar to telling someone with a hearing impairment to ‘listen up', or instructing an individual with a mobility issue to ‘walk faster'. It's important to recognise that neurodivergent traits are biological and not a matter of choice; unfortunately, they are often wrongly perceived as moral character deficits. Hence, the language we use holds significant weight. While the fight against racism and racist language remains a pertinent issue, the challenges related to ableism in the profession often go unrecognised. Many colleagues might not be familiar with this term and may unknowingly employ ableist language. Whether expressed overtly, covertly, or inadvertently, ableism is unacceptable.

Personal stories from colleagues

Abigail Craven, Dental Hygienist and Dental Therapist:

‘When my differences are met with judgement or impatience, I feel misunderstood, and I am not able to thrive in my role. I have been told that I am “being difficult” when asking for clarification, “pedantic” when noticing and correcting errors, “exaggerating” or “attention-seeking” when advocating for my sensory needs, and “careless” for misunderstanding ambiguous language. In the past these misalignments between how I am experiencing the world around me, and subsequently how I am perceived by the way I interact with the world, have led to low self-esteem, poor work satisfaction, overstimulation, shutdowns, and eventual burnout.'

Jasmine Murphy, Retired Consultant in Dental Public Health:

‘I've faced many challenges in professional settings. My energetic enthusiasm and quick idea generation were often met with scepticism. During team meetings, my tendency to hyperfocus on details were misunderstood as “overthinking”. Due to my abilities, seeking support with structured schedules were met with resistance, leaving me feeling dismissed and undermined. These experiences not only hindered my professional growth but also led to frustration, diminished self-esteem, and a constant sense of being undervalued. The subtle but impactful undercurrent of ableism in these situations further intensified the challenges I faced.'

Claire Bennett, Dental Therapist:

‘Dyslexia discrimination in dentistry is, I hope, often unintentional. I have also experienced harassment, a form of discrimination. I have been laughed at, told I am “stupid” and told I “take too long” to write notes by dental professionals. I have heard all the dyslexic jokes and comments “that they could not spell either”, in response to me informing an employer that I am dyslexic. I have received dental practice policies that prevent smartphone use in surgery which prevents me from accessing helpful, specialist software. I have been expected to read policy documents or handouts, in unreadable fonts, on white paper; and been asked to read aloud.'

Excerpt taken from: BDJ Team, May 2021: ‘Dyslexia and dentistry'.10

Neurodiversity barriers and challenges

While each person is unique, so too is their experience of their neurodiversity. Neurodiversity-related challenges may also vary with situations (making them transient) while also being subject to change due to factors such as age, health, or the environment. Due to this, colleagues may find that coping strategies previously effective in compensating for their differences may not be as reliable at certain points in their lives. During these periods, daily tasks and responsibilities might unexpectedly become even more of a challenge, posing a potential risk to their professional competence eg, time management at work. It's vital not to assume that a neurodivergent colleague is struggling with the job itself; the underlying issue could be related to sensory processing, executive functioning, or challenges arising from non-neuro-inclusive communication practices. (See part 2 to learn more about sensory processing and executive functioning: https://go.nature.com/3O7JBsx ).11 It's also important to recognise that neurodivergent colleagues often bring unique strengths to the profession by enhancing creativity, problem-solving, and innovation (Fig. 2, also read more in part 5: https://go.nature.com/3uk2Jw5 ).12,13 Understanding and embracing strengths contributes to a more inclusive workplace and team dynamics. Also see Figure 3.

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Examples of neurodiversity strengths

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Examples of barriers and challenges that can be faced by neurominority colleagues

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Personal stories from colleagues

Ben Marriott, Dental Hygienist:

‘I struggle with sensory sensitivities, particularly with sound. The university environment was hell for me, with open plan cubicles, people talking, multiple conversations when trying to concentrate on note-writing or other work in the library. There did not seem to be a single quiet area I could escape to on campus, so I would spend much of my time sitting outside, in the cold, just so I could get some peace and quiet to watch lectures on my phone. In the final year, it was required that we attend in-person lectures, and in a lecture theatre of 100 dental students with laptops clicking it was safe to say I didn't learn a single thing and would have to rewatch the lecture again at home.'

Jasmine Murphy, Retired Consultant in Dental Public Health:

‘Navigating the professional realm as a neurodivergent NHS Consultant became even more challenging during perimenopause, introducing a new layer of complexity to my neurodiversity. The intricate dance of managing my neurodiversity traits became intertwined with fluctuating hormonal changes, directly impacting my innate dopamine imbalance in my brain. The perimenopause not only magnified my neurodiversity challenges but also rigorously tested the resilience of my coping mechanisms and compensatory strategies on a daily basis.'

Reasonable adjustments

It should be noted that not all neurodivergent people identify as disabled. The Equality Act 2010 defines a disability as a ‘physical or mental condition which has a long-term and substantial effect on a person's daily life'.14 It should be appreciated that this is a legal, rather than a medical definition and therefore anyone meeting this legal definition is entitled to reasonable adjustments by law, even if they do not identify themselves as disabled.

The Equality Act 2010 covers England, Wales, and Scotland. In Northern Ireland, the equivalent legislation is the Disability Discrimination Act 199515 and the Special Educational Needs & Disability (NI) Order 2005.16 In the Channel Islands, it is the Discrimination (Jersey) Law 201317 and the Prevention of Discrimination (Guernsey) Ordinance, 2022.18

Given that neurodiversity often remains unnoticed as a form of disability, the associated barriers and required solutions for supporting neurodivergent dental colleagues are frequently overlooked. It's crucial to recognise the individualised nature of support requirements for students, trainees, and experienced dental professionals, with each facing unique challenges in their education and careers. Reasonable adjustments, including measures to remove barriers, provide the best opportunity for success in their roles. An important rule when considering reasonable adjustments for neurodivergent colleagues is to avoid making assumptions based on labels or perceived abilities/disabilities. This approach reduces the risk of direct and indirect discrimination, promoting equality. A ‘person-centred' approach, free from stereotypes, is essential in neurodiversity-informed dentistry. It involves curiosity, non-judgment, and personalised questions into what might be helpful.

For a deeper exploration of neurodivergent experiences in healthcare, education, and training, and suggested recommendations on reasonable adjustments that could be considered, refer to the linked resources provided at the end of this article.

What ‘works' will be different for each person, especially considering that many people have more than one neurodivergent condition, whether diagnosed or not. As a result, the challenges may overlap, necessitating a range of strategies and adjustments. Neurodivergent conditions often exist on a spectrum, meaning individuals may not experience all difficulties or may do so at different intensity and magnitude and at different times of their lives. In many instances, the neurodivergent individual is the best judge of what will work for them, taking into account recommendations from diagnostic reports.

Personal stories from colleagues

Abigail Craven, Dental Hygienist and Dental Therapist:

‘Some challenges I can experience due to my neurotype are to do with my working memory, processing verbal information, following ambiguous instructions, understanding abstract language, executive functioning, sensory sensitives, “bottom-up” thinking, literal and dichotomous thinking, and my communication style. When my differences are met with curiosity, empathy and understanding, my unique traits can flourish into strengths. My “bottom-up” thinking style allows me to understand concepts in great detail, enabling me to break my knowledge down and explain things well to others. I can build coping mechanisms to help with my organisation skills and share these strategies with colleagues for the betterment of the team. Adjustments that I have put in place include wearing tinted glasses and earplugs. Minimising sensory input allows for more capacity to focus on the task at hand. I keep ear defenders close by in the case of a fire alarm sounding, so that I can still look after my patient and colleagues without becoming overstimulated. Having a short commute to work and flexible hours decrease the likelihood of burnout over time.'

Ben Marriott, Dental Hygienist:

‘Some accommodations that are useful for me have been an understanding that I may need time alone to decompress in my lunch hour, early access to the surgery to prep, and clarification of what a particular meeting will be about at the time it is made to prevent overthinking and stress. One of my biggest problems is with organisation and prioritisation. If someone gives me a list of tasks to do numbered 1 to 10, I can easily work my way through them.'

Jasmine Murphy, Retired Consultant in Dental Public Health:

‘Having a supportive and understanding line manager was priceless in my professional journey. Clear and straightforward feedback, free from figurative language or hints, was greatly appreciated. Given the extra effort needed for me to socialise and integrate with the team, I was grateful for the understanding when I sought solitude. While it may have been confusing to colleagues, witnessing me happily chatting one day and choosing silence the next, this flexibility was essential for my wellbeing and effectiveness.'

Workplace initiatives

  • Disability Confident, a UK-wide government initiative, aims to inspire employers to rethink their approach to disability and proactively enhance recruitment, retention, and development strategies for disabled individuals.19 Being a Disability Confident employer presents a unique opportunity to lead the way in the dental profession (visit https://go.nature.com/49qZ1Rb)

  • The UK Health Adjustment Passport serves as a valuable tool for staff with disabilities or health conditions that can make it harder for them to undertake their role.20 It offers a structured platform to discuss the individual's condition and identify workplace changes that can support them. Regular reviews of the passport ensure that reasonable adjustments stay relevant and effective in enabling the individual to fulfil their role (visit https://go.nature.com/3wc9WPV).

Support services

  • Access to Work, a government scheme, supports employees and self-employed individuals with mental health conditions or disabilities (including neurodiversity) by offering:

    • Grants for practical work-related support

    • Help in managing mental health at work

    • Communication support at job interviews

The Access to Work grant is not income-dependent, and therefore all members of the dental team are eligible. Recipients are not required to repay the grant.21 This link covers those who live in England, Scotland and Wales: https://www.gov.uk/access-to-work. This link covers those who live in Northen Ireland: https://www.nidirect.gov.uk/articles/access-work-practical-help-work.

  • Disabled Students' Allowance (DSA) supports students with mental health conditions, long-term illnesses, or other disabilities, including neurodiversity, to cover study-related costs.22 The support provided can be on its own or in addition to any student finance received. The type of support and how much a student is provided is tailored to their needs, irrespective of household income. Like the Access to Work grant, there is no repayment requirement for the DSA. The DSA is available to students who are ordinarily resident in the UK (visit https://go.nature.com/49r9Ku8)

  • The NHS Practitioner Health Programme is a neurodiversity-aware service that provides UK wide support to NHS dentists facing challenges that impact their mental health: https://www.practitionerhealth.nhs.uk/

  • ADHD Assessment online helps colleagues with suspected ADHD gain a faster diagnosis on the NHS: http://www.adhdassessment.online/

  • Think Divergent offers free neurodiversity workplace needs assessments with personalised reasonable adjustments (www.thinkdivergent.co.uk).

Towards neuro-inclusion

Neglecting the needs of neurodivergent colleagues can result in serious consequences, not only for the individuals concerned (please read Part 5: https://go.nature.com/3uk2Jw5) but also for dental organisations through employment tribunal claims, financial loss, reputational damage and heightened risk of increased staff turnover. The General Medical Council (GMC) states: ‘we firmly believe disabled people should be welcomed to the profession and valued for their contribution to patient care'.23 It recognises that a diverse population is better served by a diverse workforce that has had similar experiences and understands their needs. While no comparable statement from the General Dental Council was identified at the time of writing, we firmly assert that the sentiment expressed by the GMC's statement should unquestionably apply to the dental profession as well. It's a ‘huge loss' for the dental profession to overlook neurodiversity as an asset or exclude individuals from the field based on traits such as social awkwardness or lack of eye contact. Dentistry inherently values neurodivergent traits, such as perfectionism, attention to detail, persistence, work ethic, loyalty, and honesty.

Given the co-occurrence of neurodevelopmental conditions, the dental profession is encouraged to adopt a ‘whole person' approach, using ‘soft skills' like listening, empathy, and compassion to gain a full understanding of the specific needs of each neurodivergent individual. By routinely asking questions, and listening to the answers, many immediate needs could be uncovered, benefitting both neurodivergent and neurotypical individuals alike. See Figure 4 for where to start.

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Where to start

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To cultivate a more inclusive and supportive culture in dentistry, dental organisations should consistently provide support and raise awareness about the unique strengths that neurodivergent colleagues bring to their roles. Creating mechanisms for neurodivergent students, staff, and colleagues to be actively involved in policies and processes ensures neuro-inclusivity. Consider setting up a staff network to amplify neurodivergent voices, promoting an environment where such voices are not just heard but truly understood. Promoting an inclusive organisational culture through transparent policies encourages individuals to disclose their neurodiversity without fear of prejudice or discrimination. Such an environment naturally facilitates access to reasonable adjustments for learning, development, and support.

Conclusion

Neurodevelopmental conditions extend beyond dental patients, impacting all members of the dental team, including students, and trainees who may have diagnosed or undiagnosed conditions like dyslexia, ADHD, and autism. The challenges faced by individuals with disabilities are contextual, particularly in a society designed primarily for neurotypical people. Central to the concept of neurodiversity is the belief that individual differences should not be perceived as weaknesses. Instead, framing neurodiversity with a strengths-based approach can lead to impactful outcomes by leveraging the capabilities of neurodivergent colleagues rather than dwelling on perceived limitations.24 In adopting a social model approach, we understand that individual differences are not the issue; instead, external barriers pose the challenge. Removing these barriers in the workplace or education setting can improve accessibility and inclusivity. This ensures that all dental colleagues and students can thrive in their places of work or learning. Embracing neurodiversity in dentistry not only enhances workplace dynamics, but it also cultivates a deeper understanding and empathy for neurodivergent patients. By doing so, the dental profession will be welcoming and including all kinds of minds.

Useful resources for managers, employees, educators, and students