ADHD & Autistic Spectrum ADHD & Autistic Spectrum DisordersDisorders

- in the Dentist’s Chair- in the Dentist’s Chair

Irish Society for Irish Society for Disability Disability and Oral Health and Oral Health

2424thth June 2011 June 2011

Fiona McNicholasFiona McNicholas

Professor Child & Adolescent Psychiatry, Professor Child & Adolescent Psychiatry, University College, DublinUniversity College, DublinConsultant Lucena Clinic, Tallaght & Our Consultant Lucena Clinic, Tallaght & Our Lady’s Hospital for Sick Children, CrumlinLady’s Hospital for Sick Children, Crumlin

Overview of talkOverview of talk

• Signs & Symptoms of ADHD, Dyspraxia Signs & Symptoms of ADHD, Dyspraxia & ASD& ASD

• Treatment considerationsTreatment considerations Setting the sceneSetting the scene

AutismAutismDevelopment of ConceptDevelopment of Concept

KolvinKolvinCreakCreak

KannerKanner AspergerAsperger

FIRST GENERATIONDESCRIPTIONS

1943

1944

1961 1971"Autistic Disturbances of Affective Contact"

Donald T. was not like other five-year-old Donald T. was not like other five-year-old boys.boys.

Donald's father wrote to Kanner describing his son as “happiest Donald's father wrote to Kanner describing his son as “happiest when he was alone... drawing into a shell and living within when he was alone... drawing into a shell and living within himself... oblivious to everything around him.” Donald had a himself... oblivious to everything around him.” Donald had a mania for spinning toys, liked to shake his head from side to side mania for spinning toys, liked to shake his head from side to side and spin himself around in circles, and he had temper tantrums and spin himself around in circles, and he had temper tantrums when his routine was disrupted.when his routine was disrupted.

In addition to the symptoms the letter described, Kanner noted In addition to the symptoms the letter described, Kanner noted Donald's explosive, seemingly irrelevant use of words. Donald Donald's explosive, seemingly irrelevant use of words. Donald referred to himself in the third person, repeated words and referred to himself in the third person, repeated words and phrases spoken to him, and communicated his own desires by phrases spoken to him, and communicated his own desires by attributing them to others.attributing them to others.

Kanner described Donald and ten other children in a 1943 paper Kanner described Donald and ten other children in a 1943 paper entitled, entitled, Autistic Disturbances of Affective ContactAutistic Disturbances of Affective Contact

In this initial description of ‘infantile autism, which went on to In this initial description of ‘infantile autism, which went on to become a classic in the field of clinical psychiatry, Kanner become a classic in the field of clinical psychiatry, Kanner described a distinct syndrome instead of previous depictions of described a distinct syndrome instead of previous depictions of such children as feeble-minded, retarded, moronic, idiotic or such children as feeble-minded, retarded, moronic, idiotic or schizoid. schizoid.

"Wild Boy of Avalon.""Wild Boy of Avalon."

Jean-Marc-Gaspard Itard Jean-Marc-Gaspard Itard • French Physician born in Provence (1775-1838) French Physician born in Provence (1775-1838) • Described and treated Victor who showed Described and treated Victor who showed

several signs of autism and is thought to have several signs of autism and is thought to have lived his entire childhood alone in the woods lived his entire childhood alone in the woods near Saint-Sernin-sur-Rance, France in 1797.near Saint-Sernin-sur-Rance, France in 1797.

• Itard treated him with a behavioral program Itard treated him with a behavioral program designed to help him form social attachments designed to help him form social attachments and to induce speech via imitation. and to induce speech via imitation.

Development of conceptDevelopment of concept

KolvinKolvinCreakCreak

KannerKanner AspergerAsperger

FIRST GENERATIONDESCRIPTIONS

1979

DSM IV CriteriaDSM IV Criteria

(I) A total of six (or more) items from (A), (B), and (C), with (I) A total of six (or more) items from (A), (B), and (C), with at least two from (A), and one each from (B) and (C)at least two from (A), and one each from (B) and (C)

(A) (A) Qualitative impairment in social interactionQualitative impairment in social interaction (>2/4) (>2/4)

• Marked impairments in the use of multiple Marked impairments in the use of multiple nonverbal nonverbal behavioursbehaviours such as eye-to-eye gaze, facial expression, body such as eye-to-eye gaze, facial expression, body posture, and gestures to regulate social interactionposture, and gestures to regulate social interaction

• Failure to develop Failure to develop peer relationshipspeer relationships appropriate to appropriate to developmental leveldevelopmental level

• Lack of spontaneous seeking to Lack of spontaneous seeking to share enjoymentshare enjoyment, interests, , interests, or achievements with other people, (e.g., by a lack of showing, or achievements with other people, (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people) bringing, or pointing out objects of interest to other people)

• Lack of Lack of social or emotional reciprocitysocial or emotional reciprocity

DSM IV CriteriaDSM IV Criteria

(B) (B) Qualitative impairments in communication (Qualitative impairments in communication (>1/4 )>1/4 )

• Delay in, or total lack of, the development of Delay in, or total lack of, the development of spoken languagespoken language (not accompanied by an attempt to compensate through (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)alternative modes of communication such as gesture or mime)

• In individuals with adequate speech, marked impairment in the In individuals with adequate speech, marked impairment in the ability to ability to initiate or sustain a conversationinitiate or sustain a conversation with others with others

• Stereotyped and Stereotyped and repetitive use of languagerepetitive use of language or idiosyncratic or idiosyncratic languagelanguage

• Lack of varied, spontaneous Lack of varied, spontaneous make-believe playmake-believe play or social or social imitative play appropriate to developmental levelimitative play appropriate to developmental level

Example of Example of Concrete Concrete

use of language-use of language-

pragmatic difficultiespragmatic difficulties

DSM IV CriteriaDSM IV Criteria

(C) (C) Restricted repetitive and stereotypedRestricted repetitive and stereotyped patterns of patterns of behavior, interests and activities (>2/4)behavior, interests and activities (>2/4)

• Encompassing Encompassing preoccupationpreoccupation with one or more stereotyped with one or more stereotyped and restricted patterns of interest that is abnormal either in and restricted patterns of interest that is abnormal either in intensity or focusintensity or focus

• Apparently inflexible adherence to specific, nonfunctional Apparently inflexible adherence to specific, nonfunctional routines or ritualsroutines or rituals

• Stereotyped and repetitive motor Stereotyped and repetitive motor mannerismsmannerisms (e.g hand or (e.g hand or finger flapping or twisting, or complex whole-body movements)finger flapping or twisting, or complex whole-body movements)

• Persistent preoccupation with parts of objectsPersistent preoccupation with parts of objects

DSM IV CriteriaDSM IV Criteria

(II) Delays or abnormal functioning in at least (II) Delays or abnormal functioning in at least one of the following areas, with one of the following areas, with onset prior onset prior to age 3 years: to age 3 years:

(A) Social interaction(A) Social interaction(B) Language as used in social (B) Language as used in social communicationcommunication(C) Symbolic or imaginative play(C) Symbolic or imaginative play

(III) The disturbance is not better accounted (III) The disturbance is not better accounted for by Rett's Disorder or Childhood for by Rett's Disorder or Childhood Disintegrative Disorder Disintegrative Disorder

Aspergers: Aspergers: • Absence of delayed language single Absence of delayed language single

words by 2, phrased speech by 3words by 2, phrased speech by 3• Normal IQNormal IQ

Problems of Syndrome Definition

Children don’t often fit into neat boxes!

“Nature never draws a

line without smudging it” Lorna Wing

FORMAL LANGUAGE

COMMUNICATIVE INTENT

IQ SOCIAL INTERACTION

Normal

Mod. Impaired

Sev. Impaired

THE GRAPHIC EQUALISER MODEL THE GRAPHIC EQUALISER MODEL OF AUTISMOF AUTISM

HIGH FUNCTIONING AUTISMHIGH FUNCTIONING AUTISM

H Cass

AUTISM AND LEARNING DISABILITYAUTISM AND LEARNING DISABILITY

FORMAL LANGUAGE

COMMUNICATIVE INTENT

IQ SOCIAL INTERACTION

Normal

Mod. Impaired

Sev. Impaired

THE GRAPHIC EQUALISER MODEL THE GRAPHIC EQUALISER MODEL OF AUTISMOF AUTISM

H Cass

Sensory difficultiesSensory difficulties

Some children with ASD also have sensory Some children with ASD also have sensory difficulties. difficulties. • Preference for over or under stimulation. Preference for over or under stimulation. • Over sensitive to light, or touchOver sensitive to light, or touch• Higher (or lower) pain thresholdHigher (or lower) pain threshold• Motor co-ordination problems Motor co-ordination problems

Depression 31%Depression 31%

Tics /Tourettes 8%Tics /Tourettes 8%

Anxiety 65%Anxiety 65%

ADHD 30%ADHD 30%

Sleep disorder 11%Sleep disorder 11%

Self-injury/aggression 43%Self-injury/aggression 43%

Obsessions and compulsions 40%Obsessions and compulsions 40%

Gringras

PREVALENCEPREVALENCE

Apparent increase in prevalence Apparent increase in prevalence since early 80’ssince early 80’s• 1 per 1000 Autism1 per 1000 Autism

• >2 per 1000 ASD >2 per 1000 ASD Recent studiesRecent studies

• Cumulative incidence rate to age 7 Cumulative incidence rate to age 7 years of 89/10,000 (Honda et al. years of 89/10,000 (Honda et al. 2005)2005)

• 5-16 years 90 /10,000. Male 1.4% 5-16 years 90 /10,000. Male 1.4% female 0.3% (ONS British Survey of female 0.3% (ONS British Survey of Child and Adolescent Mental Health Child and Adolescent Mental Health Goodman et al, 2004) Goodman et al, 2004)

• 80/10,000 Gillberg 2006 80/10,000 Gillberg 2006

Recent increase: Recent increase: • Real or we just got better Real or we just got better

diagnosing it?diagnosing it?• Broader conceptBroader concept• Redefining LD Redefining LD

Proposed for DSM VProposed for DSM V Just one category: Autistic Spectrum DisorderJust one category: Autistic Spectrum Disorder Must meet criteria 1, 2, and 3:Must meet criteria 1, 2, and 3: 1. Clinically significant, persistent deficits in social communication and 1. Clinically significant, persistent deficits in social communication and

interactions, as manifest by all of the following:interactions, as manifest by all of the following:• a. Marked deficits in nonverbal and verbal communication used for social a. Marked deficits in nonverbal and verbal communication used for social

interaction:interaction:• b. Lack of social reciprocity;b. Lack of social reciprocity;• c. Failure to develop and maintain peer relationships appropriate to c. Failure to develop and maintain peer relationships appropriate to

developmental leveldevelopmental level 2. Restricted, repetitive patterns of behavior, interests, and activities, as 2. Restricted, repetitive patterns of behavior, interests, and activities, as

manifested by at least TWO of the following:manifested by at least TWO of the following:• a. Stereotyped motor or verbal behaviors, or unusual sensory behaviorsa. Stereotyped motor or verbal behaviors, or unusual sensory behaviors• b. Excessive adherence to routines and ritualized patterns of behaviorb. Excessive adherence to routines and ritualized patterns of behavior• c. Restricted, fixated interestsc. Restricted, fixated interests

3. Symptoms must be present in early childhood (but may not become fully 3. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)manifest until social demands exceed limited capacities)

?? A further increase?? A further increase

AetiologyAetiology Poorly understoodPoorly understood Neuro-biological disorderNeuro-biological disorder

• Genetic Genetic Highly heritableHighly heritable MZ>>DZMZ>>DZ In a family with one autistic child, the chance of having In a family with one autistic child, the chance of having

another child with autism is about 5 percent -- or one in 20 another child with autism is about 5 percent -- or one in 20 -- much higher than in the normal population. -- much higher than in the normal population.

• Functional and structural abnormality with brain Functional and structural abnormality with brain • Occasionally Rubella, Tuberous sclerosis, Encephalitis, Occasionally Rubella, Tuberous sclerosis, Encephalitis,

Untreated phenylketonuria (PKU)Untreated phenylketonuria (PKU)• Not due to MMR Not due to MMR • Gene-environment interactionGene-environment interaction

CHAT Screening ToolCHAT Screening Tool The following test can be used by a Pediatrician or Family Doctor The following test can be used by a Pediatrician or Family Doctor

during the 18 month developmental check-up. during the 18 month developmental check-up. The CHAT should not be used as a diagnostic instrument, but can The CHAT should not be used as a diagnostic instrument, but can

alert the primary health professional to the need for an expert alert the primary health professional to the need for an expert referral.referral.

During the appointmentDuring the appointment• has the child made eye contact with youhas the child made eye contact with you

Get the child's attention, then point across the room at an interesting Get the child's attention, then point across the room at an interesting object and say, "Oh look! There's a (name of toy)!" Watch the child's face. object and say, "Oh look! There's a (name of toy)!" Watch the child's face. • Does the child look across to see what your are pointing at? Does the child look across to see what your are pointing at?

Get the child's attention, then give child a miniature toy cup and teapot Get the child's attention, then give child a miniature toy cup and teapot and say, "Can you make a cup of tea?" (Substitute toy pitcher and glass and say, "Can you make a cup of tea?" (Substitute toy pitcher and glass and say, "Can you pour a glass of juice?") and say, "Can you pour a glass of juice?") • Does the child pretend to pour out tea (juice), drink it, etc? Does the child pretend to pour out tea (juice), drink it, etc?

Say to the child, "Where's the light?", or "Show me the light.“Say to the child, "Where's the light?", or "Show me the light.“• Does the child POINT with his/her index finger at the lightDoes the child POINT with his/her index finger at the light

Can the child build a tower of bricks (blocks)? (If so how many?) (Number Can the child build a tower of bricks (blocks)? (If so how many?) (Number of bricks....)of bricks....)

Rain Man

InattentionInattention HyperactivityHyperactivity

ImpulsivityImpulsivity

ADHDADHD

Diagnostic criteriaDiagnostic criteria(ICD/DSM)(ICD/DSM)

Over activity Over activity InattentionInattention Impulsivity Impulsivity Symptoms before Symptoms before

age 7 (6 ICD) age 7 (6 ICD) Pervasive across Pervasive across

situation situation Cause impairment of Cause impairment of

social or educational social or educational functioning.functioning.

Not due to PDD, Not due to PDD, Psychotic or other Psychotic or other mental disorder mental disorder (anxiety, depression)(anxiety, depression)

Inattention: (6/9)Inattention: (6/9)• Fails to give close attention to details or makes careless Fails to give close attention to details or makes careless

errors in schoolwork, or other activitieserrors in schoolwork, or other activities• Difficulty sustaining attention in tasks or play activitiesDifficulty sustaining attention in tasks or play activities• Does not seem to listen when spoken to directlyDoes not seem to listen when spoken to directly• Does not follow through on instructions and fails to finish Does not follow through on instructions and fails to finish

school work, chores or duties (not due to oppositional school work, chores or duties (not due to oppositional behaviour or failure to understand)behaviour or failure to understand)

• Difficulty organising tasks/activitiesDifficulty organising tasks/activities• Avoids, dislikes or reluctant to engage in tasks that require Avoids, dislikes or reluctant to engage in tasks that require

sustained mental effortsustained mental effort• Loses things necessary for tasksLoses things necessary for tasks• Easily distracted by extraneous stimuliEasily distracted by extraneous stimuli• Forgetful in daily activitiesForgetful in daily activities

Hyperactivity/Impulsivity (6/9)Hyperactivity/Impulsivity (6/9) Fidgets with hands or feet or squirms in chairFidgets with hands or feet or squirms in chair Leaves seat in classroom or other in which sitting Leaves seat in classroom or other in which sitting

is expectedis expected Runs about, climbs excessively in situations in Runs about, climbs excessively in situations in

which it is inappropriate (restless)which it is inappropriate (restless) Difficulty playing in activities quietlyDifficulty playing in activities quietly ‘‘On the go’ or ‘driven by a motor’On the go’ or ‘driven by a motor’ Talks excessivelyTalks excessively Blurts out answersBlurts out answers Difficulty awaiting turnDifficulty awaiting turn Interrupts or intrudes on othersInterrupts or intrudes on others

Importance of Importance of impulse impulse inhibitioninhibition

Associated school problemsAssociated school problems

Language impairment 15-75%Language impairment 15-75%

Learning Disability 15-40%Learning Disability 15-40%

Low Self esteemLow Self esteem

Poor social skillsPoor social skills

Labeled ‘trouble maker’Labeled ‘trouble maker’

Associated Family problemsAssociated Family problems

Poor relationship Poor relationship with parents with parents • often secondary often secondary

and improves with and improves with appropriate appropriate interventionintervention

Family History Family History ADHDADHD

PrevalencePrevalence

ICD 1-2 %ICD 1-2 % or or DSM IV 3-5%DSM IV 3-5%

30-50% of children referred to child psychiatry clinics have ADHD30-50% of children referred to child psychiatry clinics have ADHD

Diagnosed in boys 3-4 often than in girlsDiagnosed in boys 3-4 often than in girls

Persists in 30-50% of patients into adolescence and adulthood Persists in 30-50% of patients into adolescence and adulthood (symptom profile may change)(symptom profile may change)

Ireland: Using 5% prevalence ratesIreland: Using 5% prevalence rates 888,310 0-15 year olds (2002 Census)888,310 0-15 year olds (2002 Census) 44,415 children <15yrs with ADHD44,415 children <15yrs with ADHD Increased prevalence in special schools >50%Increased prevalence in special schools >50% How many attend the dentist?How many attend the dentist?

Aetiology Aetiology Abnormal Dopamine signalling in the frontal cortexAbnormal Dopamine signalling in the frontal cortex

Deficiency of Noradrenaline in the reticular activating system Deficiency of Noradrenaline in the reticular activating system (RAS)(RAS)

the area of the brain responsible for balancing other systems the area of the brain responsible for balancing other systems involved in learning, self-control, inhibition and motivationinvolved in learning, self-control, inhibition and motivation

Highly heritableHighly heritable• Multiple interacting genes involved (DRD4, DAT1, DRD5, Multiple interacting genes involved (DRD4, DAT1, DRD5,

DRD1)DRD1)• MZ:DZ concordance of 70-80%:30:40%MZ:DZ concordance of 70-80%:30:40%• Sibling recurrence risks 25%Sibling recurrence risks 25%• Parental ADHD 15%Parental ADHD 15%• Gene-Environment interactionGene-Environment interaction

Eg maternal smoking/drinking in pregnancyEg maternal smoking/drinking in pregnancy

ADHD and the BrainADHD and the Brain

Diminished arousal of the Diminished arousal of the

Nervous SystemNervous System

Decreased blood flow to Decreased blood flow to

prefrontal cortex and prefrontal cortex and

pathways connecting to pathways connecting to

limbic system (caudate limbic system (caudate

nucleus and striatum)nucleus and striatum)

PET scan shows decreased PET scan shows decreased

glucose metabolism glucose metabolism

throughout brainthroughout brain

Comparison of normal brain (left) and brain of ADHD patient.

Other symptom patterns coexistOther symptom patterns coexist

Conduct/ oppositional disorders

ADHD

PDD Anxiety & depression

Tourette

DCD

DCD, Dyspraxia & other names..DCD, Dyspraxia & other names..

‘‘Congenital maladroitness‘ (Collier 1Congenital maladroitness‘ (Collier 1stst)) Disorder of sensory integration (Ayres, Disorder of sensory integration (Ayres,

1972)1972) ‘‘Clumsy child syndrome'. (1975, Gubbay) Clumsy child syndrome'. (1975, Gubbay) Minimal brain dysfunction Minimal brain dysfunction Developmental Coordination Disorder Developmental Coordination Disorder

(DCD)(DCD) DSM IV (WHO) Other names include:DSM IV (WHO) Other names include:

• Developmental Dyspraxia Developmental Dyspraxia listed as Specific Developmental Disorder of Motor listed as Specific Developmental Disorder of Motor

FunctionFunction

DyspraxiaDyspraxia There are three steps involved in Praxis.There are three steps involved in Praxis.

• Have an Have an ideaidea of what one wants to do of what one wants to do• OrganizeOrganize how to do it, sequence the steps involved how to do it, sequence the steps involved

(Motor planning)(Motor planning)• Take Take actionaction, or execute an unfamiliar motor activity, or execute an unfamiliar motor activity

Dyspraxia is when you have difficulty in any one Dyspraxia is when you have difficulty in any one or all of theseor all of these

The vestibular system important role in The vestibular system important role in • Balance, coordination, to sensory integration, and Balance, coordination, to sensory integration, and

planning and sequencing. planning and sequencing.

Planning…Planning…

Not everything goes according

to plan!

Developmental Coordination Disorder (DCD)Developmental Coordination Disorder (DCD)

A life-long A life-long condition condition

Boys>girlsBoys>girls 5–6% population5–6% population Impact on a wide Impact on a wide

number of areasnumber of areas

Whole Body Movement, Coordination, Whole Body Movement, Coordination, and Body Imageand Body Image

Gross motor coordination Gross motor coordination • Walking, running, climbing and jumping can be affected. Walking, running, climbing and jumping can be affected. • Poor timing. Poor timing. • Poor balance / Tripping over one's own feet is also common. Poor balance / Tripping over one's own feet is also common. • Difficulty combining movements into a controlled sequence. Difficulty combining movements into a controlled sequence. • Difficulty remembering the next movement in a sequence. Difficulty remembering the next movement in a sequence. • Problems with spatial awareness, or proprioception. Problems with spatial awareness, or proprioception. • Difficulty picking up and holding onto simple objects – pencils. Difficulty picking up and holding onto simple objects – pencils. • Clumsy - knocking things over and bumping into people accidentally. Clumsy - knocking things over and bumping into people accidentally. • Left right confusion, Cross-laterality, ambidexterityLeft right confusion, Cross-laterality, ambidexterity• Trouble determining the distance between them and other objectsTrouble determining the distance between them and other objects

Some may have general hypotoniaSome may have general hypotonia• Fatigue is common because so much extra energy is expended while Fatigue is common because so much extra energy is expended while

trying to execute physical movements correctlytrying to execute physical movements correctly

Fine Motor ControlFine Motor Control• Difficulty in handwriting, Difficulty in handwriting,

speed, grip speed, grip • Difficulty using a knife Difficulty using a knife

and fork, fastening and fork, fastening buttons and shoelaces, buttons and shoelaces, cooking, brushing one's cooking, brushing one's teeth, applying teeth, applying cosmetics, styling one's cosmetics, styling one's hair, opening jars and hair, opening jars and packets, locking and packets, locking and unlocking doors, shaving unlocking doors, shaving and doing housework.and doing housework.

Speech and Speech and Language DifficultiesLanguage Difficulties • Difficulty controlling Difficulty controlling

breathing and phonation. breathing and phonation. • Slow language Slow language

development. development. • Difficulty with feeding.Difficulty with feeding.

CognitiveCognitive

Problems with memory, esp STMProblems with memory, esp STM• Difficulty remembering instructions Difficulty remembering instructions • Difficulty organizing one's timeDifficulty organizing one's time• Remembering deadlines Remembering deadlines • Increased propensity to lose thingsIncreased propensity to lose things• Problems carrying out tasks which require Problems carrying out tasks which require

remembering several steps in sequence remembering several steps in sequence • May have excellent long-term memories May have excellent long-term memories

despite poor short-term memorydespite poor short-term memory

Sensory Integration DysfunctionSensory Integration Dysfunction Abnormal oversensitivity or undersensitivity to physical stimuli, Abnormal oversensitivity or undersensitivity to physical stimuli,

such as touch, light, and sound.such as touch, light, and sound.• Inability to tolerate certain textures or touch on skinInability to tolerate certain textures or touch on skin• Problems with oral toleration of excessively textured food (commonly Problems with oral toleration of excessively textured food (commonly

known as picky eating),known as picky eating),• Light oversensitivityLight oversensitivity• Auditory oversensitivityAuditory oversensitivity• Temperature oversensitivity. Temperature oversensitivity.

Undersensitivity to stimuli may also cause problems. Undersensitivity to stimuli may also cause problems. • Undersensitive to pain may lead to injuries Undersensitive to pain may lead to injuries

Difficulty moderating the amount of sensory information Difficulty moderating the amount of sensory information • Sensory overload, and panic Sensory overload, and panic

Problems with perception of distance, and speed of moving Problems with perception of distance, and speed of moving objects and peopleobjects and people• Problems moving in crowded places and crossing roads Problems moving in crowded places and crossing roads • Learning to drive a car may be extremely difficult or impossible.Learning to drive a car may be extremely difficult or impossible.

Issues for the DentistIssues for the Dentist

What time is a good time to go?What time is a good time to go?

Issues for anyone attending the dentistIssues for anyone attending the dentist

What time is a good time to go?What time is a good time to go?

Issues for anyone attending the dentistIssues for anyone attending the dentist

When is a good time to go?When is a good time to go? Regular check upsRegular check ups Tooth acheTooth ache Children have to go, they are taken by parentsChildren have to go, they are taken by parents

What time is good?What time is good? If it means missing class, a lot of class..If it means missing class, a lot of class.. When they are not tired, hungry, sick, infectiousWhen they are not tired, hungry, sick, infectious When they are not missing major birthday partiesWhen they are not missing major birthday parties

When is a good time for the dentist to see a lot of When is a good time for the dentist to see a lot of children?children? When they are asleep!!When they are asleep!! When they have time, are not stressed, tired, illWhen they have time, are not stressed, tired, ill When their receptionist/secretary is thereWhen their receptionist/secretary is there When the clinic is not over bookedWhen the clinic is not over booked

Issues for anyone attending the dentistIssues for anyone attending the dentist

When do these children come?When do these children come? ASD group rarely verbalize complaints re. dental problems, so regular ASD group rarely verbalize complaints re. dental problems, so regular

reviews are necessary, preventative work best but they may come with reviews are necessary, preventative work best but they may come with a lot of problemsa lot of problems

ASD children may have high pain threshold and have major dental ASD children may have high pain threshold and have major dental problems before parent is aware, making first dental appointment very problems before parent is aware, making first dental appointment very necessary but traumatic.necessary but traumatic.

ADHD children often impulsive, and increase in accidental injuries, ADHD children often impulsive, and increase in accidental injuries, broken teeth, lost braces etcbroken teeth, lost braces etc

Diet of either ASD (ritualistic faddy eaters), dyspraxia (eating Diet of either ASD (ritualistic faddy eaters), dyspraxia (eating problems) or ADHD (high sugar content craved) may lead to dental problems) or ADHD (high sugar content craved) may lead to dental carriescarries

Medications used may be linked with carries!Medications used may be linked with carries! Dyspraxic children may also have sensory under-over sensitivity which Dyspraxic children may also have sensory under-over sensitivity which

will influence when they comewill influence when they come

Issues for Children with ASD, Dyspraxia or Issues for Children with ASD, Dyspraxia or ADHDADHD

Need for sameness and continuityNeed for sameness and continuity Same room, staff, routine, sudden or unanticipated movements may be threateningSame room, staff, routine, sudden or unanticipated movements may be threatening ADHD need for structure and spaceADHD need for structure and space

Invasion of personal spaceInvasion of personal space Dentists invade everyone’s personal space. Close proximity distressing in both ASD and Dentists invade everyone’s personal space. Close proximity distressing in both ASD and

ADHDADHD

Invasive nature of oral treatment can lead to problems…Invasive nature of oral treatment can lead to problems… Self-stimulating behaviour e.g. flapping, rocking, screamingSelf-stimulating behaviour e.g. flapping, rocking, screaming Obsessive routinesObsessive routines Repetitive behavioursRepetitive behaviours Unpredictable body movementsUnpredictable body movements Self-injurious behaviourSelf-injurious behaviour Hyperactivity, quick frustrationHyperactivity, quick frustration Temper tantrums, head bangingTemper tantrums, head banging But not all of these are necessarily problems, But not all of these are necessarily problems,

some may be coping mechanisms & best left alonesome may be coping mechanisms & best left alone

Issues for Children with ASD, Dyspraxia or Issues for Children with ASD, Dyspraxia or ADHDADHD

If you understand that the screaming is a

coping mechanism, and can put up with the

child’s screaming, or mannerisms, it may be

about changing the attitude of the people

around them

Prepare othersPrepare others

Research on Dental Health & ADHDResearch on Dental Health & ADHD

Blomquist wrote a doctoral thesis on ADHD and dental Blomquist wrote a doctoral thesis on ADHD and dental

health.health. • Blomqvist M, Augustsson M, Bertlin C, Holmberg K, Fernell E, Dahllöf G, Blomqvist M, Augustsson M, Bertlin C, Holmberg K, Fernell E, Dahllöf G,

Ek U. Ek U. Eur J Oral Sci, 2005Eur J Oral Sci, 2005

• Department of Pediatric Dentistry, Karolinska Institutet, PO Box 4064, Department of Pediatric Dentistry, Karolinska Institutet, PO Box 4064, SE-141 04 Huddinge, Sweden. My.Blomqvist@ofa.ki.seSE-141 04 Huddinge, Sweden. My.Blomqvist@ofa.ki.se

BehaviourBehaviour HealthHealth AnxietyAnxiety

How do children with attention deficit How do children with attention deficit hyperactivity disorder interact in a clinical hyperactivity disorder interact in a clinical

dental examination? dental examination? A video analysis.A video analysis.

All children born in 1991 (n = 555) in one Swedish municipality.All children born in 1991 (n = 555) in one Swedish municipality. Screened for ADHD. Screened for ADHD.

• Twenty-two children with ADHD, and 47 controlsTwenty-two children with ADHD, and 47 controls The dental visit was recorded on video and analysed. The dental visit was recorded on video and analysed. Results:Results:

• Compared to the children in the control group, the children with ADHD Compared to the children in the control group, the children with ADHD made significantly more initiatives, especially initiatives that did not made significantly more initiatives, especially initiatives that did not focus on the examination or the dentist. focus on the examination or the dentist.

• The children with ADHD had fewer verbal responses and more missing The children with ADHD had fewer verbal responses and more missing responses.responses.

The children with ADHD had particular difficulties staying focused The children with ADHD had particular difficulties staying focused on the examination.on the examination.

The problems in communication resulted in less two-way The problems in communication resulted in less two-way communication between the dentist and the children with ADHD communication between the dentist and the children with ADHD than controls. than controls.

Dietary and dental hygiene habits.Dietary and dental hygiene habits.

• Less night brushing: Less night brushing: 48% in the ADHD group 82% in the control group. 48% in the ADHD group 82% in the control group.

• Less morning brushing: Less morning brushing: 48% and 75%. 48% and 75%.

• More snacking: More snacking: Children with ADHD were 1.74 times more likely to Children with ADHD were 1.74 times more likely to

eat or drink more than five times a day than children eat or drink more than five times a day than children in the control group. in the control group.

• Compared to controlsCompared to controls Children with ADHD had a significantly higher Children with ADHD had a significantly higher

number of decayed, missing, or filled surfaces (DMFS, number of decayed, missing, or filled surfaces (DMFS, 1.0 ± 1.5 vs 2.0 ± 3.0, P = 0.032) and decayed 1.0 ± 1.5 vs 2.0 ± 3.0, P = 0.032) and decayed surfaces (DS, 0.5 ± 0.9 vs 1.7 ± 3.6, P = 0.016) age surfaces (DS, 0.5 ± 0.9 vs 1.7 ± 3.6, P = 0.016) age 11 (not age 13!) 11 (not age 13!)

Dental anxietyDental anxiety

• Completed the Corah Dental Anxiety Scale (CDAS). Completed the Corah Dental Anxiety Scale (CDAS). • Cortisol measured by four saliva samples: one before Cortisol measured by four saliva samples: one before

the dental examination, one after, and two the following the dental examination, one after, and two the following morning. morning.

• The subgroup ADHD with hyperactivity-impulsivity had The subgroup ADHD with hyperactivity-impulsivity had significantly lower cortisol levels than controls 30 min significantly lower cortisol levels than controls 30 min after awakening and had a blunted cortisol reaction. after awakening and had a blunted cortisol reaction.

• The correlation between CDAS scores and cortisol The correlation between CDAS scores and cortisol concentrations before the dental examination was concentrations before the dental examination was significant in both the ADHD and the control groups. significant in both the ADHD and the control groups.

• ADHD kids do not exhibit a higher degree of dental ADHD kids do not exhibit a higher degree of dental anxiety. anxiety.

• Conclusions:Conclusions: More dental problems all roundMore dental problems all round

More Reputable Research!More Reputable Research!

‘‘Removal of the tonsils and adenoids Removal of the tonsils and adenoids has been shown to be much more has been shown to be much more effective than medication at effective than medication at improving symptoms of ADHD. ‘improving symptoms of ADHD. ‘

‘‘You are doing a disservice to your You are doing a disservice to your readers by not mentioning the No. 1 readers by not mentioning the No. 1 most effective treatment. Oxygen is most effective treatment. Oxygen is that important!’that important!’

Cosmetic dentistCosmetic dentist writing to Dr Gott writing to Dr Gott

How to PrepareHow to Prepare

How you communicate with your patientIf a child doesn’t understand the subtleties of communication, teaching them is difficult and challenging.Later: Techniques and language to use-like "Good listening" "quiet hands"

What can you doSession on what works in practice

“Tricks a

nd Tips fro

m Surg

ery A

”

Mrs. M

argaret Curra

n, Dental N

urse

& Dr. A

drianne D

olan Senior Dental S

urgeon

Special N

eeds

The professionals don’t know everything!

Advice from some mums!Advice from some mums! Tip #1Tip #1: : Find a Reputable Pediatric Find a Reputable Pediatric

DentistDentist

Tip #2Tip #2: : Choose the Day and Time of the Choose the Day and Time of the Appointment WiselyAppointment Wisely

Tip #3Tip #3: : Talk About the Experience Talk About the Experience PositivelyPositively

Tip #4Tip #4: : Read Dentist-Themed StoriesRead Dentist-Themed Stories

Tip #5Tip #5: : Watch Dentist-Themed VideosWatch Dentist-Themed Videos

Tip #6Tip #6: : Use Dentist & Teeth Use Dentist & Teeth Coloring PagesColoring Pages for Child to Color for Child to Color

Tip #7Tip #7: : Don't Delay the AppointmentDon't Delay the Appointment

Tip #8Tip #8: : Keep Up with your Child's Dental Keep Up with your Child's Dental HygieneHygiene

Tip #9Tip #9: : Don't Be NervousDon't Be Nervous

Tip #10:Tip #10: Reward Your Child for Good Reward Your Child for Good Behavior at the DentistBehavior at the Dentist

Tip #11:Tip #11:Allow Your Child to Chew Allow Your Child to Chew Sugarless GumSugarless Gum

Where can you get more infoPublished material and apps- In OFF WE GO & Social stories IApps