DIAGNOSTIC CRITERIA

The specific criteria for ADHD, as outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), are displayed in the Table.1 There are 3 subtypes of the disorder. First, there are those individuals who struggle with both inattention and impulsivity/overactivity. They must meet at least 6 of the 9 DSM-IV criteria for inattention and 6 of the 9 DSM-IV criteria for impulsivity/overactivity. These individuals will likely be diagnosed with ADHD—combined type. This is the most common form of ADHD and the subtype about which most is known.² The next most common subtype of ADHD describes individuals with primarily inattention difficulties; they will likely receive a diagnosis of ADHD—predominantly inattentive type. In the past, this subtype was referred to as ADD. These individuals must meet at least 6 of the 9 DSM-IV criteria for inattention. Some children, initially diagnosed with the combined subtype of the disorder, will “grow out” of their hyperactive/impulsive symptoms in adolescence and meet criteria for this subtype instead.³ Other children are diagnosed with this subtype in early childhood and continue to experience the symptoms as they mature. Finally, individuals with primarily impulsivity and/or overactivity symptoms will likely receive the diagnosis of ADHD—predominantly hyperactive/impulsive subtype. This subtype often describes young children who are at risk for the combined type of the disorder but have not yet reached the age where their attention problems are evident.³ Individuals with the predominantly hyperactive/impulsive subtype must meet at least 6 of the 9 DSM-IV criteria for hyperactivity/impulsivity.

It is important to note that it is not sufficient only to meet the DSM-IV criteria described above. To receive any diagnosis of ADHD, symptoms causing impairment must have been present before the age of 7 years, symptoms must cause impairment in at least 2 settings (ie, home, school, public), symptoms must cause significant impairment, and symptoms cannot be better accounted for by another disorder. ADHD can range from mild to severe. No one person has all the symptoms of the disorder.

PREVALENCE

ADHD is not an uncommon disorder. It has been estimated that 3% to 7% of children have the condition.⁴ Until recently, it was thought that ADHD was a “childhood disorder” that affected children outgrew. However, it is now known that many children diagnosed with ADHD will continue to experience symptoms of the disorder in adolescence and adulthood.⁵ With regard to gender, boys are diagnosed more frequently than are girls.⁶ However, the predominantly inattentive subtype of the disorder seems to have a more equal gender ratio.

ETIOLOGY

With regard to causes of ADHD, it is now believed that heredity accounts for approximately 80% of cases.³ Family, twin, adoption, and molecular genetic studies show that genes influence the etiology of the disorder. The children of ADHD adults are at high risk for the disorder.⁷ Further, ADHD is more prevalent in the relatives of ADHD children than in the relatives of non-ADHD children.³ Studies of identical twins have shown that when one twin has ADHD, the other twin is highly likely to have the disorder.⁸ Several candidate genes have been related to the susceptibility to ADHD (eg, dopamine transporter gene, dopamine receptor gene⁹). Other causes of ADHD include prenatal exposure to smoke, lead, or alcohol, prematurity, intrauterine growth retardation, and brain infections.^10,11 In addition, a number of genetic disorders (eg, Turner syndrome, fragile X syndrome) are associated with the symptoms of ADHD.

COMORBIDITIES

It is not unusual for individuals diagnosed with ADHD to have comorbid or co-occurring disorders. In fact, it has been found that up to 87% of children who have been diagnosed with ADHD have at least one other psychiatric disorder, and 67% have at least 2 other psychiatric disorders.¹² Specifically, research suggests that 54% to 67% of children and adolescents diagnosed with ADHD are also diagnosed with oppositional defiant disorder (a condition characterized by high levels of defiance and argumentativeness¹³). Approximately 25% of children with ADHD also have an anxiety disorder.^14-16 Similarly, between 20% and 30% of children with ADHD are also diagnosed with a mood disorder.^17-19 Bipolar disorder, a condition that has recently received much research attention, appears to co-occur with ADHD at a rate of 10% to 20%.^20-23

EVALUATION

In order to diagnose ADHD, a thorough evaluation is critical. Currently, there are no available medical or psychological tests to make the diagnosis of ADHD. Rather, the diagnosis depends on the judgment of a clinician who can evaluate whether ADHD symptoms are present, impairing, and whether or not they are not accounted for by another condition. Accordingly, a comprehensive history is crucial. Often, structured methods for obtaining information on symptoms of ADHD and other conditions are helpful to the clinician, but these measures only enhance the clinical interview. In addition, in order to rule out other conditions, it is often necessary for the individual to receive a physical or neurological examination. Finally, a psychological evaluation is often indicated to rule out learning problems and assist in identifying comorbid mental health issues.

It is important to emphasize the fact that many symptoms of ADHD are also symptoms of other medical and psychological conditions. Therefore, in diagnosing ADHD, it is imperative that the clinician rule out all other conditions that may be mimicking the symptoms of ADHD. Further, as mentioned previously, other conditions frequently co-occur with ADHD. Therefore, another goal of the evaluation is to identify comorbid conditions, as these conditions will likely impact treatment.

TREATMENT

As in the case of asthma and diabetes, the goal of treatment is to contain the disorder or reduce the symptoms rather than to cure the condition. The benefit of pharmacotherapy for the treatment of ADHD has been well established.²⁶ The medications used to treat ADHD mainly impact the neurotransmission of catecholamines.²³ Most ADHD medications fall into the category of stimulants. Some stimulants, such as Ritalin, are short-acting and are only effective for 3 to 4 hours. Children generally take these short-acting stimulants several times per day and frequently experience “rebound” or extreme irritability between doses. Long-acting stimulants, such as Concerta, can last up to 12 hours and therefore do not produce the rebound effect. They are only taken once a day.

Common side effects of stimulant medications include appetite suppression and in-somnia. Due to these side effects and others, some children are unable to tolerate stimulant medication, and nonstimulant medications are thus indicated. Recently, a nonstimulant medication, Strat-tera, has become popular for the treatment of ADHD. This medication is pharmacologically similar to antidepressant medications.

Psychosocial interventions are often very helpful with this population. One modality that is especially popular is behavior management training (eg, contingency management, positive reinforcement, time out). With behavior management training, parents and teachers can learn a variety of strategies to help them handle children’s ADHD behaviors. Behavior management training can be conducted in an individual or group format and is most helpful when dealing with preschool- and grade school-age children. Further, social skills training is often employed with ADHD children, given that many children with ADHD have social skills deficits. Social skills training is most often conducted in a group format so that children can practice the skills learned with their peers in the group. Once children become more capable of “talk therapy,” individual therapy and family therapy are particularly useful in targeting the associated symptoms of ADHD (eg, low self-esteem, demoralization). Finally, academic accommodations can be implemented to enable ADHD children to be successful in the classroom environment. Specifically, children with ADHD can benefit from a variety of classroom accommodations that include preferential seating, untimed testing, and incentives for remaining on task.

IMPLICATIONS FOR DENTAL PRACTICE

Given the prevalence and chronic nature of ADHD, it is probable that these patients will be seen in all dental practices. A number of the core symptoms of ADHD are likely to present challenges in a dental setting. For example, ADHD children tend to be restless, fidgety, and talkative, and they have difficulty remaining seated. These behaviors can certainly interfere with treatment. What follows are some issues that the clinician may wish to keep in mind when treating ADHD children.

1. Medication: Timing Is the Key

Many children with the disorder take medication. It is important to find out from the parent if the child is on any ADHD medications and if so, which medications. Further, information about the dosing schedule is crucial. Children are likely to experience the effects of stimulants 30 to 60 minutes after dosing. Therefore, in the case of an early morning dental appointment, clinicians will want to ensure that sufficient time has elapsed between dosing and the appointment. Further, as mentioned, some children will take several doses of medication per day. Between doses of short-acting stimulants, children are not covered by medication and thus may be highly symptomatic of ADHD. Further, they may experience “rebound” between doses. One would certainly want to avoid scheduling dental appointments during these “rebound” periods. Finally, information about type of medication and dosing schedules also has implications for late afternoon appointments. For example, a 4 PM appointment, which is a popular time slot for school-age children, would be far from ideal for a child on short-acting Ritalin.

2. Setting the Stage

Children with behavioral conditions such as ADHD do best when they know what to expect. Therefore, at the outset of the appointment, the clinician should inform the child about what is going to be accomplished during the appointment. Obviously, this should be done in a way that is appropriate to the child’s developmental level. If the child is having difficulty separating from the parent, the initial discussion can be done with the parent in the room. If the clinician has any indication that the child may be difficult to manage, the clinician should consider reviewing his or her expectations for this child’s behavior at this time. Finally, any incentives that can be earned by the child should be discussed, and the schedule for breaks should be reviewed.

3. Instructions

By definition, ADHD children are inattentive, and it is therefore best for the clinician to issue one instruction at a time to these children. Adults who issue multistep instructions to ADHD children often become frustrated because inattentive children are easily distracted, and consequently, they tend to forget all instructions that come later in a sequence. Due to the short attention span of these children, instructions should be relatively short and direct. When providing instructions to be implemented upon leaving the dental office, the clinician should be sure to put all important information in writing. Given that ADHD children are likely to be forgetful, disorganized, and prone to losing things, important information should always be reviewed with a parent, even in the case of adolescent patients.

4. Positive Reinforcement

Positive reinforcement, in terms of praise and small, tangible rewards (eg, stickers, pretend tattoos, baseball cards) can be useful in obtaining compliance from an ADHD child. It is known from basic behavioral theory that behaviors that are rewarded will increase in frequency. Therefore, it follows that if the clinician lets the child know that he or she is doing well (via praise or other rewards), the child will be more likely to continue good behavior. Reinforcements can be issued frequently, with younger children requiring more frequent reinforcement than older children. In addition to reinforcing unusually positive behaviors, consider reinforcing the behaviors that most adults would generally expect from a child and generally go unnoticed (eg, great job following directions, great job listening, great job sitting patiently). There is really no such thing as too much reinforcement, al-though the clinician should at-tempt to be genuine when issuing praise.

If a child is particularly challenging, the clinician might consider providing the child with a token every few minutes if he or she is on task. (Of course, it would be important to explain to the child at the outset exactly what is expected of him or her.) At the end of the appointment, the child could be given the opportunity to cash in his or her tokens for a small treat from the dental office or from the parent. The clinician should be sure that the incentive that is being offered is something that the child really values and will work toward, otherwise this strategy will be ineffective. It might be useful to create a “treasure chest” filled with a variety of small tangible rewards that would appeal to both boys and girls of a variety of developmental levels. Feel free to consult with a parent about what reinforcers might be effective with a particular child and do not hesitate to ask a parent to bring reinforcements to the dental office to be used during the appointment.

5. Behavioral Contracting

Clinicians may find behavioral contracting to be a useful technique, particularly when dealing with especially challenging children. Contracts can be either verbal or written. Verbal contracts often take the form of a “when…then” statement. For example, the clinician might offer that when he or she is done polishing the child’s teeth, then the child can play his or her Gameboy for a brief period of time. Written contracts are similar but seem more formal, particularly since they are signed by the patient and clinician. With a written contract, children may feel more accountable for keeping up their end of the agreement than they would if only a verbal contract was utilized.

6. Breaks

Breaks are an important component in working with ADHD children. Breaks are likely to be effective even if they are very brief. So, when it is possible to provide breaks during a procedure, the clinician should consider doing so. If possible, allow the child to get out of the dental chair during the break. The clinician may opt to set a timer during breaks so that the child will know that the break is “officially” over. Clinicians might consider asking parents to provide a favorite activity (eg, coloring supplies, book) or preferred toy (eg, Gameboy, toy cars, doll) for the child to use during the breaks. For guidelines on whether breaks will be necessary, how often to provide breaks, and duration of breaks, the clinician should consider consulting with the child’s parents. If the clinician has decided to use breaks, he or she should inform the child at the beginning of the appointment that breaks will be given during which the child will be able to play. The clinician can take this opportunity to let the child know what he or she expects from the child during the rest of the appointment when they are not on a break.

7. Transitions

ADHD children live in the moment and often experience difficulties transitioning from one activity to another. It is unlikely that they will resist taking a break from a dental procedure, but they very well may have difficulty transitioning from a break back to the dental chair. To facilitate such transitions, be sure to give the child advance notice that the break is almost over (eg, “you can play for 2 more minutes and then we need to get back to work”). When the time comes to make the transition, be sure to praise the child for complying if the transition was accomplished in a timely manner without the child fussing.

DISCUSSION

ADHD is a complex disorder. Those who are affected by it can be quite significantly impaired, presenting challenges to all who work with them. It can be very difficult and frustrating to work with these children, particularly when operating within typical time constraints. Clinicians should not hesitate to let parents know that they are having difficulty managing their children. In all likelihood the parents have heard this before from other professionals. Further, parents will likely appreciate the fact that the clinician is deferring to their expertise in this area. Parents may be able to provide the clinician with some simple tips that will likely work with their child. If the clinician feels that he or she is becoming too involved in behavior management with a particular child, it is reasonable to ask the parent to remain in the treatment room so that the parent can manage the child’s challenging behaviors while the clinician is engaged in the dental procedure. Do not forget to make use of parents as a valuable resource. They are truly the experts in regard to their children.

SUMMARY

ADHD is a common disorder that affects individuals of all ages. A thorough evaluation is necessary to make an accurate diagnosis. Symptoms of the disorder can be managed by pharmacological and psychosocial interventions. Due to the high baserate of the disorder as well as its chronic nature, ADHD patients are likely seen frequently in any dental practice. Accordingly, it is necessary for the clinician to be familiar with the disorder as well as with strategies for managing it.

References

1. Applegate B, Lahey BB, Hart EL, et al. Validity of the age-of-onset criterion for ADHD: a report from the DSM-IV field trials. J Am Acad Child Adolesc Psychiatry. 1997;36:1211-1221.

2. Barkley RA. Primary symptoms, diagnostic criteria, prevalence, and gender differences. In: Barkley RA. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 2nd ed. New York, NY: Guilford Press; 1998:56-96.

3. Stein MA, Efron LA, Schiff WB, et al. Attention deficits and hyperactivity. In: ML Batshaw. Children With Disabilities. 5th ed. Baltimore, Md: Paul H. Brookes Publishing Co; 2002:389-416.

4. Szatmari P. The epidemiology of attention-deficit hyperactivity disorders. In: Weiss G, ed. Child and Adolescent Psychiatry Clinics of North America: Attention Deficit Hyperactivity Disorder. Philadelphia, Pa: WB Saunders; 1992:361-371.

5. Barkley RA. Developmental course and adult outcome. In: Barkley RA. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 2nd ed. New York, NY: Guilford Press; 1998:186-224.

6. Sharp W, Walter JM, Marsh WL, et al. ADHD in girls: clinical comparability of a research sample. J Am Acad Child Adolesc Psychiatry. 1999;38:40-47.

7. Biederman J, Faraone SV, Mick E, et al. High risk for attention deficit hyperactivity disorder among children of parents with childhood onset of the disorder: a pilot study. Am J Psychiatry. 1995;152:431-435.

8. Cook EH Jr. Genetics of attention-deficit hyperactivity disorder. Mental Retardation and Developmental Disabilities Research Reviews. 1999;5:191-198.

9. Faraone SV. Report from the third international meeting of the Attention-Deficit Hyperactivity Disorder Molecular Genetics Network. Am J Med Genet. 2002;114:272-276.

10. Accardo P. A rational approach to the medical assessment of the child with attention-deficit/hyperactivity disorder. Pediatr Clin North Am. 1999;46:845-856.

11. Mercugliano M, Power TJ, Blum NJ. The Clinician’s Practical Guide to Attention-Deficit/Hyperactivity Disorder. Baltimore, Md: Paul H. Brookes Publishing Co; 1999.

12. Kadesjo B, Gillberg C. The comorbidity of ADHD in the general population of Swedish school-age children. J Child Psychol Psychiatry. 2001;42:487-492.

13. Angold A, Costello EJ, Erkanli A. Comorbidity. J Child Psychol Psychiatry. 1999;40:57-87.

14. Tannock R. Attention-deficit/hyperactivity disorder with anxiety disorders. In: Brown TE. Attention-Deficit Disorders and Comorbidities in Children, Adolescents, and Adults. Washington, DC: American Psychiatric Press; 2000:125-170.

15. Biederman J, Newcorn J, Sprich S. Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders. Am J Psychiatry. 1991;148:564-577.

16. Pliszka SR. Comorbidity of attention-deficit hyperactivity disorder and overanxious disorder. J Am Acad Child Adolesc Psychiatry. 1992;31:197-203.

17. Fischer M, Barkley RA, Smallish L, et al. Young adult follow-up of hyperactive children: self-reported psychiatry disorders, comorbidity, and the role of childhood conduct problems and teen CD [published correction appears in J Abnorm Child Psychol. 2003;31:563]. J Abnorm Child Psychol. 2002;30:463-475.

18. Biederman J, Faraone SV, Lapey K. Comorbidity of diagnosis in attention-deficit hyperactivity disorder. In: Weiss G, ed. Child Adolescent Psychiatry Clinics of North America: Attention-Deficit Hyperactivity Disorder. Philadelphia, Pa: WB Saunders; 1992:335-360.

19. Cuffe SP, McKeown RE, Jackson KL, et al. Prevalence of attention-deficit/hyperactivity disorder in a community sample of older adolescents. J Am Acad Child Adolesc Psychiatry. 2001;40:1037-1044.

20. Carlson GA. Child and adolescent mania—diagnostic considerations. J Child Psychol Psychiatry. 1990;31:331-341.

21. Wozniak J, Biederman J, Kiely K, et al. Mania-like symptoms suggestive of childhood-onset bipolar disorder in clinically referred children. J Am Acad Child Adolesc Psychiatry. 1995;34:867-876.

22. Wozniak J, Biederman J. Prepubertal mania exists (and coexists with ADHD). The ADHD Report. 1994;2:5-6.

23. Wilens TE, Faraone SV, Biederman J. Attention-deficit/hyperactivity disorder in adults. JAMA. 2004;292:619-623.

Dr. Efron is a clinical psychologist at Children’s National Medical Center, Washington, DC, where she serves as training director for psychology and director of the Hyperactivity, Attention, and Learning Problems (HALP) Clinic. Dr. Efron has research interests relating to ADHD, children’s sleep difficulties, and parenting practices. She is an assistant professor of psychiatry and pediatrics at the George Washington University Medical Center in Washington, DC. Dr. Efron received her bachelor’s degree from Columbia University in New York City and her master’s degree and doctorate from Duke University in North Carolina. She did her clinical internship at Johns Hopkins University and the Kennedy Krieger Institute. She can be reached at (571) 226-8339 or lefron@cnmc.org.

Dr. Sherman is a diplomate of the American Board of Oral Electrosurgery and a fellow of the American College of Dentists and the International College of Dentists. He is the executive director of the World Academy of Radiosurgery and maintains a private general dental practice in Oakdale, NY. He can be reached at (631) 567-2100 or esurg@aol.com.

Developing a practice that is emotionally healthy is paramount to achieving personal and professional success. The dentist?s willingness to look openly at and address workplace practices and to develop healthy workplace practices in the office will have a profound effect on contentment and fulfillment.

This article will address a topic highly relevant to successful dental practices: creating and managing a practice that is psychologically and emotionally healthy for employees and owners.

THE COST OF NOT HAVING A HEALTHY WORKPLACE

Even more important than technical skills, the ability to manage a practice will determine the practitioner?s success. Of course, technical skills and knowledge are paramount to clinical success in dentistry, but appropriate concern for the health of the workplace may ultimately determine professional fulfillment.

Unhealthy workplace practices account for a high rate of employee turnover, increased absenteeism, high levels of workplace stress, chronic conflict, emotional abuse, work sabotage, and even workplace violence. Employees? perception of their work-life imbalance becomes amplified, health and well being may suffer, and costs for medical care, insurance, and time off due to illness will increase. Employees can develop drug and alcohol addictions as a coping mechanism for dealing with stress. The result will be a decrease in productivity, profitability, and fulfillment.

When the workplace environment is unhealthy, the cost exacted upon the dentist can be staggering. Dentists can suffer from the same stress-related maladies as the employees and can become angry, disillusioned, disappointed, depressed, and overly fatigued. It interferes with the ability to enjoy life’s work. The passion for dentistry is lost, and even worse, for helping people—one of the major reasons for individuals to become a dentist. And because of the solo ownership nature of most dental practices, it is unclear if others feel the same way.

MAKING A DENTAL PRACTICE A BETTER PLACE TO WORK

In 1999, the American Psychological Association (APA) recognized and understood the tremendous cost to businesses of any size of not having workplaces that are conducive to sound psychological health. That year, this association introduced an award to recognize organizations that made a commitment to workplace well-being and creation of a psychologically healthy workplace for employees.¹

According to a 2000 poll by the APA, two thirds of both men and women say work has a significant impact on their stress level, and one in 4 has called in sick or taken a “mental health day” as a result of work-related stress.² Healthcare expenditures are nearly 50% greater for workers who report high levels of stress.³ Any organization that recognizes these issues and strives to address them not only helps its employees but improves the organization. When workers can manage stress and balance their work and their life, productivity improves. Workplace practices can have a significant effect on employee commitment, satisfaction, and health.^4,5

When the economy is challenging, companies (and dental practices) seek to cut costs associated with employees, such as reducing health insurance benefits, decreasing work hours and fringe benefits, and placing less emphasis on work environment enhancements and improvements. Expending more effort and money to create a healthy workplace might appear to be a better choice in times of abundance rather than during an economic downturn, but this is not always true. These investments are needed when the workplace environment is unhealthy.

WHAT IS A HEALTHY WORKPLACE?

There is no single model of the healthy dental workplace. No one practice is exactly like any other. In general, practices that are healthy are those that have engaged employees: the employees feel invested in the success of the practice because they see the practice has invested in their success. Practices have begun to see real benefits to investing in their employees’ emotional and physical health.

Improving communication throughout the organization (thereby increasing employee involvement in decision-making) or providing flexibility to balance work and personal issues are significant workplace practices. In fact, according to a 2002 job satisfaction poll conducted by the Society for Human Resource Management and USA Today, these are among the most important issues for employee satisfaction.⁶ Prince has stated that companies are finding that not only do healthy workplace practices make employees more satisfied, but also more productive.⁷

Employee Involvement

Clear and candid communications, a voice in decision-making for employees, a fair employee performance evaluation system, and recognition for individual and team performance are needed.

Cawley, et al, looked at the importance of a fair employee performance evaluation system that gives feedback and enhances performance. They found that when given the opportunity, employees actively participate in performance appraisals (voicing their opinions), and consequently there was an increase in perceived fairness of the appraisal process, increased motivation to change following the appraisal, and increased ratings and satisfaction of the appraisal process.⁹

Parker, et al, examined variables that contribute to safe work practices, namely the quality of communication, job autonomy, supportive supervision, and safe-working protocols. They determined that managers can do more than introduce rules, punishments, or other control measures. They must also demonstrate a supportive, coaching management style, enrich the workplace by enhancing job autonomy, and communicate and share information with their employees.¹⁰

Brown and Leigh demonstrated the impact of a perceived healthy psychological climate in the workplace on employees’ effort and performance. The components of that climate were the extent to which management was perceived as flexible and supportive, role clarity, freedom of self-expression, employees’ per-ceived contribution toward organizational goals, the adequacy of recognition received from the organization, and job challenge.¹¹ 

Policies must consider personal and extended family needs.

Psychological research can impact workplace conditions so as to create workplace policies and practices that affect the human condition.¹² It was noted that 85% of the US work force now live with family members; 62% of mothers with infants and toddlers, 68% of mothers of preschoolers, and 77% of mothers of school-aged children are em-ployed; and 69% of all men and women have elder care responsibilities. It was concluded that “One outcome of these shifting demographics may be a legitimization of the work-family balance issue such that companies become more aggressive in establishing policies and practices that are more family-friendly.”

Earlier, Fernandez quoted the Public Personnel Management journal as saying, “Employees who perceive supervisors as understanding of family related demands have better attendance, are more productive, and stay with companies longer.”¹³

Zedeck and Mosier re-viewed the difficulties of balancing family and work de-mands. They examined different approaches organizations can take to ease this burden. They discovered that family-friendly organizations are praised as the most desirable companies to work for. They also found that workers who are absent to deal with family issues can lead to decreased productivity, preoccupation with childcare problems can cause decreased concentration at work, and trouble with scheduling childcare often causes lateness.¹⁴

The National Research Council found that a lack of social support from supervisors in regard to family issues was highly correlated with employee depression, low levels of organizational commitment, and the number of physical complaints that were filed.¹⁵

Employee Growth and Development

Offering programs that deal with workplace stress and conflict and allow easy access to psychological services.

The importance of addressing mental health in the workplace was examined by Sauter, et al, and they proposed specific mechanisms by which organizations might become more psychologically supportive. In 1990, it was noted that 11 million people reported health-endangering levels of mental stress while at work, including excessive work load, lack of job/career security, and poor interpersonal relationships in the work environment.¹⁶

Hatfield noted that the United States was the world’s most technologically advanced nation, but only ranked fifth in terms of productivity per worker. He stated that worker stress is one major reason for this contradiction.¹⁷

Systems can be implemented to improve employee morale and bolster job performance. One such program that contributed to employees’ growth and development is a program at the Ohio State University College of Osteopathic Medicine. Its program included increased communication, input into decision-making, adequate coverage for needed vacations and absences, and recognition of accomplishments and contributions.

In the healthcare setting, a 2-year longitudinal study showed that the introduction of stress-management programs in hospitals correlated with reduced malpractice claims. The stress-management programs included having consultants implement policy changes to manage stress, such as encouraging employee feedback and having employees watch a videocassette training series on understanding stress. Also, an employee counseling program was implemented that allowed employees and their families to seek help for both work-related and personal problems.18 The efficacy of psychoeducational stress-re-duction programs in improving both psychological health and job performance of emergency medical workers has also been examined. Three types of stress reduction treat-ments were examined: progressive muscle relaxation, coping skills training, and interpersonal awareness training. All 3 interventions were associated with improved performance on both psychological and job performance measures.¹⁹

Easy access to a wide range of psychological services, not just traditional substance abuse programs, means that employees are more likely to experience a psychologically healthy workplace. Baba, et al concluded that having mental health problems in the workplace resulted in decreased job involvement, satisfaction, and performance and increased turnover and absenteeism.²⁰ Martin published statistics on the impact of mental health on a company’s profits. Depression, for example, costs businesses $47 billion a year in disability claims. Martin also reported that depressed employees were less productive.²¹

Health and Safety

A priority should be placed on employee health and safety.

There are numerous studies that illustrate the impact of placing a priority on health and safety in the workplace. One of the most important was by Gebhardt and Crump. This report outlined a number of fitness programs that have been implemented by various organizations and the positive impact realized by those organizations.²²

Practicing dentists are aware of Occupational Safety and Health Administration (OSHA), state, and federal guidelines and mandates for having a workplace that is free of potential health dangers as well as the protection that is needed for employees. Additionally, preparation of workplaces for potential medical emergencies serves to comfort employees and emotionally prepare and support them during these times. Having medical emergency protocols, CPR training, and readily available equipment such as an automated external defibrillator and portable oxygen tanks are just some of the actions companies take to promote a healthy workplace.

Recommendations for Creating a Healthy Workplace

(1) Get help. Consultants, professional coaches, psychologists, counselors, human relations specialists, and therapists all can contribute to the effort to create a healthy work environment. It is important to work with someone familiar with healthy workplace practices, with a focus on dental practices.

(2) Be honest and listen to the consultant and to the employees. Is the workplace healthy or unhealthy? Each practice should be evaluated on the criteria set forth in this article and by the APA. Staff should be involved in that evaluation.

(3) Discuss strengths and weaknesses as a team. Enlisting the feedback and opinions of staff is one way to begin to create a healthy workplace.

(4) Dentists do not attend dental school to learn how to run a business and manage the everyday personnel, personal, and business aspects of a dental practice. Clinical expertise will not help here. The dentist must not allow ego to get in the way of the changes that are needed.

(5) Engage and encourage all employees to develop programs, strategies, and actions that meet and address healthy workplace practices. Other dental practitioners who have accomplished this should be consulted. It is also important to discuss this issue with other business owners not in the dental field and enlist their advice and assistance. It is important to read available literature on good workplace practices.

(6) It is important not to be overly concerned with the cost of the program. Most dental staff members are well paid in comparison to other businesses, and salary is generally not the issue here. In brief, for dental practices, developing a healthy workplace is usually not very expensive.

(7) Let the staff be involved. Most staff members want to do a good job and will be supportive of positive changes in the practice. It is important to listen, develop meaningful and professional relationships with them, and enlist them as partners in the practice.

(8) The dentist must continue to grow personally and professionally. Positive change by the dentist-owner can be a positive catalyst for the em-ployees.

(9) Other experts may need to be consulted. For example, attorneys are one resource who might be needed to develop agreements and policies consistent with state, local, and national guidelines, as well as to protect the dentist and his or her employees. Additionally, consultants that specialize in specific areas such as OSHA compliance can offer advice and recommendations that save time and money and re-duce stress.

(10) Meet regularly with employees. Listening, problem-solving, sharing successes, recognizing contributions, planning, and setting goals will enhance productivity and well-being and foster success. 

CONCLUSION

The importance of a having a healthy workplace cannot be overemphasized. Financial and personal success is strongly linked to the ability to create, lead, and manage a healthy workplace. Now more than ever, putting effort into developing employees, offering opportunities for their growth and development, and showing genuine concern for their well-being, will both create a healthy work environment and positively affect the productivity of a dental practice.

References

1. American Psychological Association. Psychologically healthy workplace best practices 2004 [brochure]. Available at: http://www.apapractice.org/apo/psychologically_healthy.html#. Accessed November 2004.

2. National Survey of Public Opinion On Seeking a Mental Health Professional, Work Stress, and Related Issues (press release). Washington, DC: Am Psychological Assoc; Dec 14, 2000:10.

3. Lehmer M, Bentley A. Treating work stress: an alternative to workers? compensation. J Occup Environ Med. 1997;39:63-67.

4. Schmidt WC, Welch L, Wilson MG. Individual and organizational activities to build better health. In: Murphy LR, Cooper CL, eds. Healthy and Productive Work: An International Perspective. Philadelphia, Pa: Taylor & Francis; 2000:133-147.

5. Williams S. Ways of creating healthy work organizations. In: Cooper CL, Williams S, eds. Creating Healthy Work Organizations. Chichester, England: John Wiley & Sons; 1994:1-5.

6. Esen E, Dincin B, Frigault J. Job Satisfaction Poll. Society for Human Resource Management and USA Today. 2002:27-28. Available at: http://www.shrm.org/surveys/Job%20Satisfaction%20Poll.asp. Accessed November 2004.

7. Prince M. Employers seek to quantify work/family benefit savings. Business Insurance. 1999;33:3-15.

8. American Psychological Association. Psychologically Healthy Workplace Award [brochure]. Available at: http://www.apapractice.org/apo/psychologically_healthy/psychologically_healthy0/psychologically_healthy.GenericArticle.Single.articleLink.GenericArticle.Single.file.tmp/PHWA_Brochure.pdf. Accessed December 14, 2004.

9. Cawley BD, Keeping LM, Levey PE. Participation in the performance appraisal process and employee reactions: a meta-analytic review of field investigations. J Appl Psychol. 1998;83:615-633.

10. Parker SK, Axtell CM, Turner N. Designing a safer workplace: importance of job autonomy, communication quality, and supportive supervisors. J Occup Health Psychol. 2001;6:221-228.

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Dr. Deems is a practicing dentist and professional personal and business coach in Little Rock, Ark. In 2004, he became the first dentist to receive a national Best Practices award by the APA, one of only 10 businesses in the US to be honored. In 2003, he received the Psychologically Healthy Workplace Award, given by the Arkansas Psychological Association. He can be reached at drdeems@drdondeems.com or at (866) 663-9903.

As a dentist, assume you want to influence this man toward the best dental health he can achieve. Influencing people is not easy. You may need to influence him to change a number of behaviors, including the following:

•Adopt certain self-care habits such as brushing and flossing.

•Accept certain dental procedures that, in and of themselves, are not very appealing; only their results are appealing.

•Psychologically take responsibility for his dental health rather than passively depending upon the dentist, whereas the larger healthcare system in our country encourages dependency.

•Learn enough about his oral situation to make informed choices.

•Spend money on dental health that may have been targeted for other areas.

Psychologists report that people are most effectively influenced within the context of a meaningful relationship. Therefore, if this middle-aged man is your patient, you must build a relationship with him in order to do your best work. Such relationships go beyond rapport and good chairside manner. Good rapport ensures superficial cordiality and pleasant behavior as long as there is low stress. As every dentist knows, dental treatment often involves high stress. Creating relationships that go beyond good rapport is not easy, and the skills required to do so are not taught in dental school.

EMOTIONAL INTELLIGENCE

The skills needed to create influential relationships require dentists to have or develop psychological knowledge. The concept of emotional intelligence (known colloquially as EQ) has organized psychological knowledge so that non-psychologists can use it to develop the skills necessary to build powerful relationships. EQ has gained prominence because it has been proven to have substance and utility. It rests on a growing body of research of more than 20 years. Finally, EQ skills can be learned and developed. A low-EQ person today can become a stronger EQ person tomorrow.

EQ identifies specific skills that can be tested for relevance and value in specific work settings such as dentistry. For example, (1) high-EQ executives add 127% more to their company’s bottom line than average performers¹, (2) high-EQ software experts add 320% more value than average performers^2,3, and (3) high-EQ sales people sell more than their counterparts with lower EQ.^1,4-6

It stands to reason that if EQ can contribute to the success of people in these roles, it is likely to contribute to success for dentists. (For a more complete account of the value of EQ in the workplace, refer to The EQ Edge by Steven Stein and Howard Book [2000] and Working With Emotional Intelligence by Daniel Goleman [1998].)

Definition of EQ

EQ can be defined as the set of skills people use to read, understand, and respond intelligently to the emotional signals sent to us by others and ourselves. It allows us to understand and adjust our reactions to events and people and enable us to influence others.

Research by psychologist Reuven Bar-On, PhD, has identified 15 distinct skills that comprise the overall concept of EQ. His list includes skills such as self-regard, assertiveness, empathy, stress tolerance, and optimism. Studies have found that different occupational roles require different combinations of these EQ skills for maximum success.^7,8 For example, the skills needed by CEOs to achieve maximum success are different from those needed by people who are software experts or who have a career in sales.

THE PANKEY STUDY OF EQ

For over 30 years, The Pankey Institute has been a world leader in training dentists in advanced dental techniques. The core of the Pankey philosophy states “It is essential for the dentist to establish a deep, mutually rewarding relationship with the people whom she or he treats.” To test the utility of EQ skills for dentists, the institute conducted a study that proposed to answer 2 questions: (1) Do EQ skills contribute to a dentist’s success in implementing a relationship-based model of dental practice? And (2) if so, which EQ skills are most important for the dentist to master in order to implement the model?

The study was patterned after one done with US Air Force recruiters.⁸ In the mid-1990s, the Air Force was losing half of its recruiters every year, with a price tag of $30,000 for each replace-ment. It was a problem that had resisted solution for years. The Air Force knew that recruiters need certain technical skills but did not know which emotional skills were most critical for success. They undertook a study to learn which of the 15 EQ skills identified by Dr. Bar-On are most associated with recruiter success. Dr. Bar-On’s psychological measure of EQ, the Emotional Quotient Inventory (EQ-i), was administered to 1,171 recruiters. Test results were compared to job performance.

Recruiters strong in 5 skills (assertiveness, empathy, happiness, emotional self-awareness, and problem solving) were 270% more likely to achieve their recruiting quotas than recruiters weak in those skills. Furthermore, successful recruiters worked fewer hours than less successful recruiters. (EQ may have implications for overworked dentists.) The Air Force began to screen recruiter candidates with the EQ-i for strength in these 5 EQ skills. In addition, it trained incumbent recruiters in the same skills. Within 1 year, recruiter retention skyrocketed to 96%, saving $2.7 million per year.

A similar study was done with 76 CEOs of successful companies.9 It was found that these CEOs were, on average, superior to the general population in 5 EQ skills: independent thought, assertiveness, optimism, self-actualization, and self-regard.

METHOD

To conduct our study, we needed to compare the EQ of dentists well-versed in the Pankey model with the success that they have had in implementing that model in their practice. To measure implementation, we created a 92-item self-report instrument, the Survey of Progress (SOP). (Note: Paul Henny, DDS, a Pankey-trained dentist practicing in Salem, Va, helped Dr. Ackley develop the initial version of this questionnaire.) It asks dentists to report the frequency with which they engage in Pankey-encouraged behaviors in the following 3 areas: (1) technical diagnostic skills taught at the institute; (2) behavioral steps of relationship building (such as initial patient interviews, codiscovery, and team development); and (3) business practices that benefit both patient and dentist.

Participants had to have completed at least 6 weeks of training at the institute to ensure they had deep exposure to the Pankey practice model. Two hundred twelve dentists responded to recruitment letters. Of those, 144 (130 men and 14 women) provided a complete set of responses. Their ages ranged from 33 to 63 years, with a mean age of 48.6 years. (Note: This article briefly summarizes a sophisticated study protocol. Complete study data are on file at The Pankey Institute, [305] 428-5500.)

RESULTS

A positive, statistically significant correlation (+0.44) was found between the total EQ-i score and the SOP, meaning that as EQ scores go up, so do SOP scores. Similar correlations were found between 13 of the 15 EQ skills and total SOP score. Thus, EQ in general appears to be a key component in successful implementation of the Pankey practice model.

The second goal of the study was to identify which EQ factors are most important to that success. A regression analysis found that the 4 components of EQ that are most critical to success are emotional self-awareness, reality testing, assertiveness, and self-actualization.

Emotional Self-Awareness

Emotional self-awareness (ESA) is the ability to notice that you are having an emotional reaction and to recognize which emotion is being experienced (eg, anger or sadness). Such knowledge is significant information that we can use to decide how best to respond to a situation.

Highly skilled individuals in technical fields such as dentistry and engineering often have been trained to think of emotions as frivolous and unimportant. They strive to maintain objectivity. Objectivity, unfortunately, cannot be achieved by ignoring emotion. Denial does not make feelings go away. It does lead us to miss the information that emotions can provide. Only when we recognize our emotion can we then put that part of our response into its proper perspective and achieve objectivity when necessary.

Imagine a tired dentist with the last patient of the day. This patient presents with unexpected needs that exceed the scheduled time but cannot be ignored. If the dentist tries to ignore his or her own frustration, he or she is likely to express it in some unrecognized way (perhaps with curt answers to questions). Such responses will decrease the dentist’s long-range ability to influence dental health. Dentists who recognize and accept their frustration are in a position to control how it is expressed, perhaps by saying something like “We are going to have to be here a little longer this evening than either one of us would like, but we will make this right for you.”

How does emotion help you know how to respond to people to deepen the influence of your relationship? Imagine that you feel annoyed with a patient. Because you noticed the feeling, you can now ask yourself “I wonder what my irritation means?” The answer is apt to provide information that will help you identify a strategic response that fits this particular patient in this particular encounter. For example, suppose you take pride in empowering patients while this patient is behaving in a highly passive and dependent manner. Recognizing the source of annoyance gives you a conscious choice about how to respond. You might opt to accept that this patient is more passive than you would like. Alternatively, you might choose to take steps to help the patient learn how to increase active participation in her or his own oral health. Either way, you are less likely to express annoyance in a way that may harm the relationship.

Our emotions sometimes come from our own thoughts and memories rather than external events. For example, perhaps the patient with whom you are annoyed physically reminds you of someone you intensely dislike. Recognizing the reaction and its source can alert you that you have unconsciously confused these 2 people in your mind, a surprisingly common occurrence. This knowledge can lead you to step back, recognize the differences between the 2 people, and respond to the person who is actually in the chair.

Reality Testing

Reality testing is the victory of judgment over raw emotion. Good reality testing occurs when we are able to keep our emotions from excessively influencing our interpretations of events. For example, if some people are reasonably optimistic, they have assessed a situation cognitively, seen possibilities (that pessimists miss), then have added the emotional seasoning of hope.

People often have trouble with reality testing in 2 ways. First, people sometimes wear rose-colored glasses because they want something to be true so much that they ignore data to the contrary. For example, imagine yourself in this situation: you have worked many hours on a major, comprehensive treatment plan. You are justifiably proud of your creative competence. Furthermore, your practice has been a little slow in recent months. While financial pressures have not compromised your clinical judgment, you can’t help but recognize that the fees from this case will ameliorate a “tight spot.” If you are wearing rose-colored glasses, you might jump to the conclusion that your patient is ready to agree to treatment and miss signs that the patient has reservations.

Conversely, some people misinterpret events from a negative perspective. A dentist may fear rejection and misinterpret a comment from a patient as disinterest in a treatment plan when that was not the patient’s intent. Such dentists commonly back away from presenting plans that might be well-received.

Strong reality testing contributes to sound judgment. The dentist whose reality-testing skills are well-developed can read situations for what they are without the excessive intrusion of hopes or fears. A common area of denial in dental practice is staff conflict. The dentist with strong reality testing is less likely to fall into the trap of pretending staff conflict could never happen  “because everyone likes each other.” In reality, liking and conflict do coexist. This dentist will recognize staff conflict for what it is and is positioned to develop a strategic response.

Finally, strong reality testing can enhance hiring accuracy. Rather than hoping that a receptionist will work out, dentists with strong reality testing perform due diligence in screening potential employees. They learn to recognize the personality limitations that may make an otherwise qualified candidate a poor fit for their office.

Assertiveness

Assertiveness is the ability to articulate one’s wants and needs in a constructive fashion. It is often confused with aggressiveness. We are aggressive when we try to force our ideas on someone else. Assertive communication occurs when we express what we want, think, and feel in a manner that creates the following subtext: “I’m not going to hurt you and I’m not going to let you hurt me. We are both safe here.”

Assertiveness helps establish trust, an essential part of the Pankey model. The assertive dentist is more capable of developing a nonthreatening doctor/patient relationship (which is not easy, given that many people feel threatened before they walk into the reception area). Assertiveness helps dentists create win/win outcomes wherein both doctor and patient leave the encounter feeling they got all they wanted and often more. For example, the patient receives dental treatment while feeling both safe and respected. The dentist is allowed to do her or his best work, gets paid, and earns the patient’s gratitude. Win/win experiences build long-term cooperative relationships that tolerate the stress that is often  part of dental experiences.

Assertiveness also helps dentists in their role as office team leader. The successful dentist has established a vision, either formally or informally, that guides practice development and maintenance. An assertive dentist is better equipped to help staff understand the vision. When staff members understand what is expected of them, conflict is reduced. Assertively communicating clear expectations eliminates the power vacuum that occurs when people “fill the void” with their individual visions. Dentists who fill the void with their vision—in a nonshaming, nonthreatening way—will have happier, more cooperative staffs.

Self-actualization

Self-actualization is the ability to engage our passions and talents. The more we see ourselves as developing and learning along lines that feel important to us, the higher our self-actualization score is likely to be.

Self-actualization has 2 elements: passion for our work, and interests outside our work life. People who score high on self-actualization are more likely to be involved with their families,  communities, and other interests while enjoying their practice. A man recently captured the 2 parts of self-actualization beautifully when he said, “I’m a lucky guy. I’m looking forward to going home to be with my family and all we will do this weekend. Come Monday morning, I’ll be excited about getting back to the office.”

The life balance of self-actualization contributes to success because taking a break from the job creates refreshment and clearer thinking. While not measured by SOP, a long-standing principle taught at The Pankey Institute is “Dentists and patients benefit when dentists establish balance in their lives.”

STUDY SURPRISES

We expected to find self-regard, empathy, and interpersonal relationships to be essential skills for success with this model. Indeed, their respective correlations with SOP scores were 0.44, 0.25, and 0.31, meaning that as dentists’ skills in these areas were shown to be stronger, their SOP scores were higher. While we continue to believe that these are important skills, they were not found to discriminate more successful Pankey dentists from less successful individuals. Whatever is measured by these components of the EQ is also measured–and measured more effectively–by the parts of the EQ related to emotional self-awareness, reality testing, assertiveness, and self-actualization.

STUDY CONCLUSIONS

The results of this study support the belief that emotional intelligence is a key component in the successful implementation of the Pankey relationship model of dental practice. Those participants who have higher emotional intelligence report better success in implementing the technical skills and business practices taught at Pankey. We believe this is because their higher EQ skills help them create relationships in which patients are engaged in positive health choices.

Specifically, the emotional intelligence skills that are most important to success appear to be emotional self-awareness, reality testing, assertiveness, and self-actualization. Thus, if a dentist is bogged down in the transition from a traditional practice model to a Pankey-style model, it may be that one or more of these skills have not been sufficiently developed. Since these EQ skills can be learned, this need not be a permanent barrier to success. The results of this study have implications for all dentists who seek to achieve success and fulfillment in practice and life.

References

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Dr. Becker is the chairman of education at The Pankey Institute for Advanced Dental Education. He can be reached at ibecker@pankey.org.

Dr. Ackley is a consulting business and organizational psychologist. He is a guest presenter at The Pankey Institute. He can be reached at (540) 774-1927 or danaackley@prodigy.net.

Dr. Green is director of business systems development at The Pankey Institute. He can be reached at rgreen@pankey.org.