'He won't sit still!' (because he can't)

How to work effectively with ADHD patients

by Lisa Dowst-Mayo, RDH

Let me know if you've experienced this before. It's two o'clock in the afternoon and you have 30 minutes for a child prophy. Mom shows up eight minutes late, so now you're down to 22 minutes. You have to take two bitewings, two occlusal "cookies" films, do a prophy, fluoride, and give oral hygiene instructions. Then you have to flip your room and get ready for the next patient, with three more to go after that. So, if you run 15 minutes late with this patient, it means you'll be leaving late from work that evening.

You seat your 9-year-old patient and quickly realize things are not going to run smoothly. He is bouncing all over the place, will not sit still in the chair, and keeps asking over and over again, "What's that? What do you use that for?" On top of this, it appears as if the child has not brushed his teeth for a week, or maybe he's been using the wrong end of the toothbrush! Ever been here?

This article provides tools that will allow you to work with this little guy with a lot more grace and flow-ability then you ever thought possible. I am going to give you tips that will enable you have the know-how in communicating, handling, and appealing to patients who exhibit this type of behavior and the kind of patient I am referring to is the child was has attention deficit hyperactivity disorder (AD/HD).

In dental hygiene school I learned about AD/HD as part of my course in pediatrics. There was a 15-minute discussion of AD/HD with very few tips on handling this kind of patient in the dental office. I know most of you out there can relate. The truth of the matter is we run into these patients almost daily in our practices, and a 15-minute discussion on the topic cannot prepare us for the reality of treating these kids. This is the reason for this article – all dental professionals need to know more about AD/HD and ultimately how to identify and care for children who come into our offices with this disorder.

This article addresses the:

• Definition of AD/HD and comorbid disorders (adjunctive disorders that can occur along with AD/HD)
• Basic statistics associated with AD/HD
• Known causes of AD/HD
• Misconceptions surrounding AD/HD
• Treatment and diagnosis of AD/HD
• Helpful hints for dental office treatment

As I was researching for this article, I learned the disorder ADD no longer exists, which surprised me greatly. To date, there are now only three classified forms of AD/HD. It is important to note that no single person has all the signs or symptoms or displays any of these disorders in the exact same way.1,2 The three forms of AD/HD are:

1. AD/HD: Predominately Inattentive Type – This used to be referred to as ADD without hyperactivity or undifferentiated ADD. Many still refer to this type as ADD.2
2. AD/HD: Predominately Hyperactive/Impulsive Type
3. AD/HD: Combined

AD/HD itself is defined as a medical condition caused predominately by genetic factors that results in certain neurological differences.3 It is a developmental disorder of self-control or the inability to regulate behavior with an eye toward the future.1,3 Children with AD/HD have a significant impairment in the ability to inhibit behavior that affects daily life.2

AD/HD consists of five primary problems in a person's ability to control behavior:

1. Difficulties with sustained attention and increased distractibility
2. Impulse control or inhibition
3. Excessive activity
4. Difficulty following rules and instructions
5. Excessive variability in their responses to situations

There are at least five professional organizations that include a number of scientific presentations on AD/HD each year. A national organization was founded in 1987 named CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder) and has more than 20,000 members. The organization's Web site – www.chadd.org – is a useful tool for professionals as well as parents.

With such a long-term, rich history, it is surprising there are still people who advocate that AD/HD is not a real disorder, or that it is something psychologists in the United States made up to define the "misbehaved" child. AD/HD has been recognized as a true medical condition by multiple agencies, such as the Americans with Disabilities Act, Individuals with Disabilities in Education Act, the U.S. Surgeon General, National Institutes of Health, U.S. Department of Education, Centers for Disease Control and Prevention, American Medical Association, American Academy of Child and Adolescent Psychiatry, American Psychiatric Association, American Psychological Association, and the American Academy of Pediatrics.2,3

Statistics

If AD/HD is left untreated or undiagnosed, it can lead to severe impairment and a life full of failure and underachievement. Statistics tell us 30% to 50% of these kids will repeat a grade level at least once, 35% of those may fail to graduate from high school, more than 60% have severely impaired social relationships, and their defiant behavior can lead to resentment by other siblings, frequent school punishments, and greater potential for substance abuse later on.2,3 People with low economic status are the highest risk group for undiagnosed or untreated AD/HD. Children in foster care or adopted children also have higher rates of AD/HD than the general population.

AD/HD is diagnosed at least three times more frequently in boys than girls. Since girls generally have the ability to inhibit behavior more than boys, many times they are not diagnosed as quickly. Girls more commonly have the inattentive type of AD/HD rather than the hyperactive type. Some statistics show many more girls have AD/HD but they are not being diagnosed correctly because, unlike boys, the disorder is not as evident.2 Raising a child with AD/HD is costly for parents. They will spend two times the amount of money in medical bills and special services, such as psychiatry, than those parents who are raising a child without AD/HD.

Chances are you encounter one or two of these children in your practice each day or at least weekly, depending on the number of children you treat. As you can see, it is imperative that we, as dental professionals, learn more about this disorder and the appropriate ways to support the needs of these kids.

Causes

AD/HD is a lifelong disorder. About 80% of children will continue to exhibit impairments related to AD/HD into their adolescence, and 67% into adulthood. Evidence is quickly mounting that AD/HD is a disorder in brain development or functioning that originates in genetics and appears to involve the orbital-frontal region, which is the part of the brain responsible for inhibiting behavior, sustaining attention, employing self-control, and planning for the future. If a child has AD/HD, there is a 50% chance one parent has AD/HD as well. Ongoing research into whole genome studies look at a patient's entire family history. Two definite, identified genes associated with AD/HD are named D4RD and DAT1.1,6 D4RD is related to the personality dimension known as novelty seeking. Children with AD/HD are more likely to have this form of this particular gene that makes them display more novelty-seeking behaviors. DAT1 helps to regulate dopamine activity in the brain by influencing how quickly dopamine is removed from the synapse.

Researchers think certain neurotransmitters in the brain may be deficient in those with AD/HD, and this is why stimulant and nonstimulant medications are effective in many who have the disorder. Those medications affect neurotransmitters temporarily; some medications also increase dopamine and norepinephrine in the brain, which seems to improve behavior.

Dopamine levels are also believed to play a part in AD/HD. Spinal samples of kids with AD/HD have shown decreased levels of dopamine in some research, but other research using urine samples disagrees.3 As reported in the literature, dopamine pathways in the brain, which link the basal ganglia and frontal cortex, appear to play a major role in AD/HD. It is thought that kids with AD/HD may have disturbances in their dopamine-signaling systems.

There are many misconceptions surrounding this disorder. By identifying these misconceptions, we can rule out what we now know does not cause AD/HD and, in turn, rule out treatments that will not work. A child with AD/HD is not a "bad" or "misbehaved" kid, and AD/HD is not just a matter of being inattentive and overactive. It is not a temporary state; children will not outgrow it. You cannot just wait for it to go away.1,2,3 Parents do not contribute to a child developing AD/HD by not disciplining or controlling their child correctly or by having a chaotic family lifestyle. To date there is absolutely no evidence supporting any of these widespread claims regarding nutritional, environmental (such as watching too much television), or hormonal factors.

Diagnosis

There are multiple entities and/or a combination of professionals who can diagnose and treat AD/HD. Medical doctors are sometimes the first professionals a parent will consult when they suspect that their child needs to be evaluated for AD/HD. In May 2000, the American Academy of Pediatrics published guidelines for diagnosis. Other professionals capable of making a diagnosis of AD/HD using the correct guidelines are psychiatrists, clinical psychologists, clinical social workers, neurologists, as well as other qualified medical and mental health professionals.

Treatment

What's more important for health-care professionals, as well as parents, is not to try to figure out what caused AD/HD in the child, but to learn how to manage the disorder and help the child succeed in life. There are many treatment options for AD/HD, and each child will have different needs and be in need of different treatments. What works for one child may not work for the next, because AD/HD manifests itself differently in each individual. No single intervention will be effective for treating and managing AD/HD.

The main thing to keep in mind when discussing treatment options is that the best way to manage the disorder is with a multimodal treatment. This type of treatment involves parents, professionals, and child educators in diagnosis, treatment, behavior management techniques, medication, school programs, and/or special accommodations.1,2,3 "Treatment should be tailored to the unique needs of each child and family," according to the CHADD Web site.

Of course medications are the main treatment option everyone is aware of and around which controversy swirls. While this is a viable and useful tool for patients with AD/HD, it is not recommended to be the only treatment. Only one-sixth to one-half of children with AD/HD are medicated.3 The classes of medications most commonly used are stimulant and non-stimulant drugs. Stimulants are drugs that work primarily by increasing the action of certain chemicals that occur naturally in the brain, mainly dopamine and norepinephrine.1

Nonstimulant medications slow down the reuptake of norepinephrine back into the nerve cells in the brain, thus norepinephrine is more readily available and in higher quantities.4

The FDA requires pharmaceutical companies to develop medication guidelines for each of the medications.1,3,4 You can access these guides at www.fda.gov/cder/drug/infopage/ AD/HD/default.htm (see Table 1).

There is much trial and error when it comes to finding the right medication in the right dosage for patients with AD/HD. The main issue is that we don't know which neurotransmitter in the brain is affected in people with AD/HD, and therefore we will not know what medication will affect the right neurotransmitter. Generally, most medications work by slowing down the neurotransmitters in the synaptic gap of the brain, which ultimately slows down the whole process so the child can get all the information from the neuron. Without it, the information is in and out of their head quickly and does not allow time for the child to process the information.

Once the right medication is finally identified, then the issue becomes finding the right dosage. It could take up to a year to get the right dosage and medications in people suffering from AD/HD. It is important to mention that medications do not teach skills; all they do is help the child focus enough to learn the skills they need to learn. Again, a multimodal approach to treating AD/HD is advocated by all professionals.

Comorbidity disorders

There are many types of spectrum disorders that affect children; AD/HD is not the sole issue out there. About 70% to 80% of children with AD/HD suffer from co-occurring (comorbidity) mental disorders, such as oppositional defiant disorder (40% to 65%), conduct disorder (10% to 25%), anxiety disorder (25% to 40%), depression (10% or 30%), learning disabilities (20% to 60%), or sleep problems (50%). Two-thirds of young children and teens with AD/HD have additional coexisting disorders.2,3,5

Oppositional defiant disorder (ODD) is diagnosed when a patient exhibits patterns of negative, hostile, and defiant behavior that has been evident for at least six months. It occurs more frequently in people with AD/HD than is typical in individuals of comparable age and developmental levels, and it causes significant impairment in social, academic, or occupational functions.

When a child with AD/HD is in "ODD mode," it is close to impossible to connect with them. The child needs to be pulled out of that mode quickly before any disruptive behaviors start to emerge. One of the best ways to accomplish this is to find what the child is interested in and question them about it. For example, "So, I heard you like Thomas the Train. What color is he?" Many kids who have AD/HD can be pushed into an ODD mode easily. It is best that a dental appointment does not take place during an ODD mode. Reschedule the visit for another day and time when the child is more calm and relaxed.

Many children with AD/HD also have sensory integration disorders, for example. These can be tactile, auditory, visual, processing, etc. These kids can have problems with things we use in the dental office. They can be hypersensitive to heat and cold and be oversensitive to touch. If you give a gentle touch on the shoulder or the back to a child with a tactile sensory disorder, it can feel like an electric shock. They actually do better with deeper, more deliberate touches, and it is always better to warn them before you touch them.

Helpful hints for dental office treatment

The more open and candid parents are with us, the better and smoother appointments will run. The most challenging situation is when a parent refuses to admit the child may have an issue or is in need of an AD/HD evaluation. We are then left to work with a challenging child who will find it extremely difficult to control his or her behavior in a dental office setting.

Here are some helpful hints to use in the dental office setting. Do not "cattle call" these patients to the back. Go up to them and their parents, shake their hand, pat them on the back, bend down to their level, and tell them how happy you are to see them.

When trying to talk to a child with AD/HD, it is best to use short, concise words and instructions. The fewer words you use, the better. Use "alpha commands," which are clear and well stated. Use a neutral, firm, matter-of-fact tone of voice; keep your voice as monotone as possible. According to AD/HD professionals, these children are always on high alert for changes or inflections in your voice. They are vigilant of others and the environment. It is never a good idea to use connotative, harsh, or negative words when talking to them.

Kids who have AD/HD do not transfer learning from one day to the next. If they made a mistake yesterday, without reminders, they will make it again today. So it would be important for parents to preplan with their child before their dental visit and also bring something to keep them occupied while waiting. Since they are lacking in internal controls, parents need to provide external motivation (e.g., if you have a good visit, we can stop for lunch on the way home).

Morning appointments are usually best for AD/HD kids, because their attention span is better. It is also important for you to try to shorten appointments as much as possible. This means you need to be 100% prepared for that appointment and not have to leave the room for something you forgot. Clearly define for these patients what the appointment will entail, especially in more complicated procedures such as sealants. Specify exactly what your expectations are. If you are doing things such as opening instruments or setting up while trying to tell these patients something important, they may not hear you because they are more interested in what you are doing than what you are saying. Give one direction or command at a time, then wait five seconds for that command to process and the child to comply before moving on.

Ignore minor inappropriate behaviors. For example, they may put their hands up by their face rather than at their side. If this happens, either simply move their hands over their stomach or ask them to do it themselves. You don't have to explain why, just use clear, concise instructions. Sometimes the fluorescent lighting in offices can cause issues as well. It can actually stimulate an AD/HD child, causing distractions during the appointment.

Positive reinforcement systems are extremely useful tools for children with AD/HD. For any effective motivation, people must see meaning and value – this credo applies to all human beings, not just children who have AD/HD. However, rewards used with AD/HD kids must be changed frequently. These kids love novelty, so a reward that worked six months ago may not work today.

Children and teens who have AD/HD respond to positive praise very well. They like positive attention because they do not always get it, so be generous with your praise. Focus first on what they are doing well and praise them for it. Children with AD/HD are in trouble a lot. If you ask them a question, they will tell you what they think you want to hear. Avoid questions that set a child up for a lie. If you know they are not flossing their teeth don't ask them if they are. That will not get you the results you are trying to achieve. When you note something they are not doing well enough, such as flossing, use positive words to discuss their need to floss. Don't bark orders or demands at them, because they will tune you out. Ask what professionals call "I wonder" questions to help the child understand the importance of flossing. For example, say: "I wonder what happens to teeth when someone doesn't floss." Wait for them to think of an answer and then expand on that. Use smiles and gentle pats on the back, high fives, or thumbs-up.

If the child is on medications, parents need to make sure they took their medication on the day of the appointment. Many children do not take their medication over the summer or on weekend breaks due to an old train of thought that stimulant medications may stunt a child's growth. Longitudinal studies, though, have shown that this growth difference is minimal or all together non-existent.

Parents of kids with AD/HD often report they have an extremely difficult time getting their child to brush daily, even more than the average child without AD/HD. Their unwillingness to commit to most oral hygiene procedures is at a higher intensity and deficiency. My best suggestion to parents is to find out what motivates their child and use that to help with oral hygiene compliance. Pictures work extremely well, so maybe hanging pictures of people with rotted teeth on the bathroom mirror would be a good nonverbal cue to remind the child each day of the importance of brushing.2,6 Again, these children are constantly being corrected about their behavior issues, so the last thing they want to hear at the end of the day is another command such as, "Go brush your teeth." Oral hygiene instructions in writing hanging in their bathroom or a checklist may be useful as well. Warn parents that they will need to update those pictures or written instructions over time when the novelty starts to wear off. Electric toothbrushes with timers may work well; the child may think it is more fun to use than a manual brush.

Oral hygiene instructions have to be interesting to AD/HD patients or they will not pay attention to what you say. They are not being rude; they just cannot sustain attention to a conversation in which they have no motivation or interest. Make eye contact and face the patient when you speak. If you seem interested in the conversation, they will pick up on that and their interest may increase. Always use positive instructions. Avoid saying don't or using words with negative connotations. Have patients repeat your instructions in their own words; this will help them clarify what you just said. Never have these conversations while a TV is on. The fewer auditory distractions, the better. Never talk to the child while he or she is in a supine position. Avoid multistep instructions, and put all home-care instructions in writing.

If you finish your appointment and are just waiting on the doctor for an exam, make sure these children are occupied. There is no harm in letting them get down and maybe get a prize from the prize box. Just be sure to tell them that the appointment is not over and they will have to get back in the chair shortly for the doctor to look at their teeth. This way they know what is expected of them and what is coming next. Using exact time with AD/HD kids is not a useful tool. They have a hard time understanding exactly how long or short two minutes is; instead, just say they need to be back in your chair in a short while, or use a timer.

Some published studies have shown that children who have AD/HD may have higher pain tolerances than kids without AD/HD. This may make it hard for some children to know they have a severe cavity in a tooth, for example. When you ask them if that tooth hurts, they may not be lying when they say no. It may also be true they did not want to tell their parents for fear of getting in trouble, but it may also be that the tooth actually does not hurt.

Treating a patient who has AD/HD does not have to be a painful or strenuous experience. If you use the tools in this article effectively, you will see how much easier it is to communicate and appeal to this type of patient. Just remember to be calm, patient, and understanding – not only with the child but with the parents as well. For more information about AD/HD, see the references below.

Lisa Dowst-Mayo graduated from Baylor College of Dentistry in 2002 with a Bachelor's degree in dental hygiene. She is a member of ADHD, TDHA and a board member of the San Antonio Dental Hygiene Society. She works as a private practice clinician in San Antonio and is a free-lance CE speaker and author. She has published articles on dental lasers and contemporary periodontal therapies over the past three years. She resides in Boerne, TX with her husband and two beautiful children.

References

1. Dendy C. Teenagers with ADD and AD/HD. Bethesda, Md.: Woodbine House, Inc. 2006.
2. Rief S. The AD/HD book of lists. San Francisco, Calif.: Jossey-Bass, 2003.
3. Barkley R. Taking charge of AD/HD. New York, N.Y.: The Guilford Press, 2005.
4. Dendy C, Durheim E. CHADD educator's manual. Landover, Md.: CHADD, 2006.
5. Silver L. The misunderstood child. Bradenton, Fla.: TAB Books, 1992.
6. Silverman I. 101 school success tools for students with AD/HD. Waco, Texas: Prifrock Press Inc. 2010.