1st national interprofessional healthcare symposium. Collaborative care: A multidisciplinary approach to special needs dental patients.

Background: King George’s Medical University's skill building platform, KGMU B.E.S.T (Building Essential Skills through Training), in collaboration with the Down Syndrome Federation of India, organized the 1^st National Interprofessional Health Care Symposium on the theme “Collaborative Care: A Multidisciplinary Approach to Special Needs Dental Patients” on 13th September 2025. The symposium was inaugurated by Honourable Vice Chancellor of King George’s Medical University, Dr Soniya Nityanand. Dean of the Faculty of Dental Sciences, Dr. GK Singh, Dr. Anjoo Agarwal, Organizing Chairperson, Dr. Rhythm, Organizing Secretary, and Dr. Promila Verma, Scientific Coordinator, were actively involved in organizing the event and the scientific sessions.

Objectives: The symposium aimed to bring together health professionals from various backgrounds, including genetics, oral health, physical rehabilitation, psychiatry, and nursing care, to highlight the importance of a collaborative approach in managing oral health issues in patients with Down Syndrome.

Major Findings: The event was conducted in a hybrid mode and was well-attended by over 100 onsite and 170 online participants from all over India and the SAARC countries, including Nepal & Sri Lanka. There were 80 undergraduate and postgraduate poster entries under various themes.

Recommendations: Interprofessional, multidisciplinary, and collaborative care is the need of the hour for managing patients with special needs, as they often present with multiple health issues. An interprofessional approach should be incorporated into the curriculum from early career stages to help students understand the holistic management of patients, rather than adopting a compartmentalized approach.

Key Sessions

Eminent keynote speakers, Dr. M. Pradeep Kumar and Dr. Nidhi Gupta from the Down Syndrome Federation of India, shared their knowledge and expertise. A multidisciplinary session was conducted, featuring various experts from different fields, including Dr. Vivek K. Bains from Periodontology, Dr. A.K. Gupta from Physical and Medical Rehabilitation, Dr. Pawan Gupta from Psychiatry, and Ms. Anjali Arora from Nursing Care. Dr Rameshwari Singhal and Dr Richa Khanna organized a role-play on the symposium theme. Undergraduate and postgraduate students actively participated in a poster competition, presenting their unique ideas.

01 Sensitisation of healthcare professionals to genetic counselling and rare diseases: Emphasising the role of early diagnosis and support in Down syndrome

M. Pradeep Kumar¹

¹Consultant Clinical Geneticist, Gene-Omm- Centre for Genetic and Rare Diseases, Coimbatore, India.

Objectives: To sensitise medical practitioners toward the significance of genetic counselling and early detection of rare diseases, with a particular focus on Down syndrome as a model for multidisciplinary management and family support.

Material and methods: An interactive sensitisation program was conducted for healthcare professionals, encompassing lectures, case discussions, and audiovisual modules that illustrated the clinical presentation, genetic mechanisms, and psychosocial aspects of rare diseases. Emphasis was placed on the genetic basis, prenatal diagnosis, and postnatal management of Down syndrome, highlighting the importance of referral pathways and counselling frameworks.

Results: Post-program feedback demonstrated enhanced understanding among participants regarding the identification of genetic disorders, the role of genetic counselling, and the integration of multidisciplinary care for patients with rare diseases. Increased awareness was particularly noted in the domains of communication with families, ethical considerations in prenatal testing, and early intervention strategies for Down syndrome.

Conclusion: Sensitising doctors to the principles of genetic counselling fosters timely diagnosis and compassionate care for individuals with rare diseases. Focused educational initiatives can bridge the knowledge gap and promote equitable access to genetic services, especially for conditions such as Down syndrome, where early intervention can greatly improve quality of life.

Keywords: Down syndrome, Early diagnosis, Genetic counselling, Medical education, Rare diseases, Sensitisation

02 More than meets the eye: Dental dooms in special needs - obvious and hidden

Nidhi Gupta¹

¹Consultant Endodontist, Director, Maximus Dental, New Delhi, India.

Objectives: To highlight the overlooked and emerging oral health challenges faced by individuals with special healthcare needs (SHCN), emphasising both the apparent and subtle “dental dooms” that impact their overall quality of life.

Material and methods: A narrative synthesis was performed drawing upon current literature, clinical case experiences, and interdisciplinary insights related to oral health in SHCN populations, including patients with Down syndrome, autism spectrum disorder, cerebral palsy, and rare genetic conditions.

Results: Findings revealed that while conditions such as dental caries, periodontal diseases, and malocclusion are commonly recognised, hidden morbidities-like altered salivary biochemistry, medication-induced xerostomia, and chronic inflammatory burden-often go unnoticed.

Contributing factors include behavioural challenges, inadequate professional training, and limited access to specialised dental care, all of which exacerbate disease progression and delay treatment.

Conclusion: Oral health management for special needs populations must adopt a holistic, inclusive, and preventive approach that addresses both the visible and hidden burdens of disease. Early screening, caregiver sensitisation, and interprofessional collaboration are essential to prevent these “dental dooms” and enhance quality of life.

Keywords: Disability dentistry, Down syndrome, Hidden oral disease, Inclusive oral care, Oral-systemic link, Special healthcare needs

03 Periodontal considerations in Down syndrome: Clinical insights, pathophysiology, and emerging therapeutic strategies

Vivek Kumar Bains¹ https://orcid.org/0000-0002-2232-9742

¹Department of Periodontology, Saraswati Dental College & Hospital, Lucknow, India.

Objectives: To synthesise current evidence on the prevalence, etiopathogenesis, clinical presentation, and therapeutic considerations of periodontal disease in individuals with Down syndrome, emphasising preventive and emerging non-surgical interventions.

Material and methods: A narrative review and critical synthesis of published literature were conducted, integrating landmark and recent studies on periodontal manifestations in DS, covering microbial, immunological, histopathological, and clinical domains. Emphasis was placed on mechanistic pathways, therapeutic strategies, and public health perspectives relevant to both pediatric and adult DS populations.

Results: Nearly 90–100% of individuals with DS under 30 years exhibit clinical or radiographic evidence of periodontitis, with early onset and rapid progression affecting the anterior regions predominantly.

Key pathogenic mechanisms include:

• Vascular and connective tissue abnormalities leading to poor perfusion and altered collagen turnover.

• Immune dysfunction ( chemotaxis, phagocytosis, T-cell response, and IgA/IgG; IL-10, MMP activity, oxidative stress).

• Anatomic and behavioural predispositions (macroglossia, open bite, poor manual dexterity, institutionalisation stress).

Emerging therapies-including antimicrobial photodynamic therapy, melatonin gel, probiotics, and chlorhexidine gels-show promising results in adjunctive management. However, limited DS-specific randomised clinical trials constrain evidence-based recommendations. A preventive, caregivercentred approach remains pivotal.

Conclusion: Periodontitis in Down syndrome represents a multifactorial, systemic manifestation requiring lifelong preventive care, multidisciplinary management, and public health prioritisation. Integration of caregiver education, early screening, and simplified non-invasive therapies could improve quality of life.

Keywords: Down syndrome, Immunological dysfunction, Melatonin, Oral health policy, Periodontitis, Photodynamic therapy, Probiotics, Regenerative periodontology

04 Multidisciplinary care special needs dentistry: Physical & medical rehabilitation considerations

Anil Kumar Gupta¹ https://orcid.org/0000-0002-7524-3635

¹Department of Physical Medicine and Rehabilitation, King George’s Medical University, Lucknow, India.

akgupta@kgmcindia.edu

Objectives: To highlight the role of multidisciplinary care and rehabilitation-based approaches in improving oral health management for patients with special needs.

Material and methods: A narrative review of clinical challenges, rehabilitation strategies, and multidisciplinary approaches was undertaken, with emphasis on accessibility, medical clearance, anaesthesia planning, and adaptive aids. Case-based experiences from a tertiary rehabilitation department were integrated.

Results: Key challenges include physical impairments (e.g., cerebral palsy, spasticity), comorbidities (epilepsy, cardiac disease, diabetes), and behavioural barriers. Rehabilitation considerations such as wheelchair accessibility, adaptive oral hygiene aids, and feeding/swallowing rehabilitation enhance functional outcomes. Proactive management through spasticity control, orthotic interventions, and the use of adaptive devices improves the feasibility of dental care. A multidisciplinary team, including dentists, physiatrists, therapists, speech pathologists, psychologists, and caregivers, was found to be essential. Literature indicates that access to dental care for individuals with IDD in India remains limited due to infrastructure and training gaps, underscoring the need for integration of special care dentistry in curricula.

Conclusion: Dental care for patients with special needs should not be isolated but rather embedded in a rehabilitation-oriented, multidisciplinary framework to enhance safety, oral health, and quality of life.

Keywords: Disability, Multidisciplinary care, Oral health, Rehabilitation, Special needs dentistry.

05 Psychological considerations in children with Down syndrome

Pawan Kumar Gupta¹ https://orcid.org/0000-0001-7523-5988

¹Department of Psychiatry, King George’s Medical College, Lucknow, India.

gpawan2008@gmail.com

Background: Down syndrome (DS) is the most common chromosomal cause of intellectual disability, with a unique cognitive and socio-emotional profile. Beyond physical comorbidities, children with DS frequently face behavioural and psychological challenges that impact their development, learning, and family functioning. Early recognition and tailored intervention are key to improving developmental outcomes.

Objectives: To discuss the psychological manifestations, behavioural problems, and management considerations in children with Down syndrome through clinical and psychosocial perspectives.

Material and methods: A narrative and case-based review of behavioural and emotional features associated with DS was undertaken, integrating clinical observations, multi disciplinary management strategies, and a representative case vignette 10-year-old male with DS presenting with aggression and self-injurious behaviour).

Results: Children with DS often present with varying degrees of intellectual disability, expressive language delay, hyperactivity, anxiety, and emotional dysregulation. Behavioural problems such as impulsivity, tantrums, aggression, and self-injurious or inappropriate sexual behaviours may emerge, especially during adolescence. Management emphasises early behavioural interventions, structured environments, positive reinforcement, and caregiver psychoeducation. Pharmacological support (e.g., risperidone or aripiprazole) is reserved for severe behavioural disturbances and is always complemented by behavioural and psychosocial interventions.

Conclusion: Comprehensive care for children with DS requires early identification of behavioural issues and individualised, multidisciplinary management. A strengths-based approach that integrates behavioural therapy, parental guidance, and supportive psychopharmacology can optimise adaptive functioning and quality of life.

Keywords: Behaviour problems, Down syndrome, Intellectual disability, Psychological management, Self-injury,

06 More than a smile: Oral health in children with Down syndrome

Anjali Arora¹

¹King George’s Medical University College of Nursing, King George’s Medical University, Lucknow, Uttar Pradesh, India.

anjaliarora.94@gmail.com

Background: Beyond the physical features, Down syndrome is associated with various health challenges that can affect the overall quality of life. Thus, the role of nurses cannot be neglected. They play a crucial role in coordinating care, referencing the unique oral health challenges. There are three key components of effective oral health: brushing your teeth, cleaning your tongue, and rinsing your mouth after every meal. For promoting oral hygiene, nursing care strategies are based on three pillars: prevention, Adaptation, and Consistent routine. Prevention should focus on promoting effective oral hygiene practices, dietary guidance, and the importance of regular dental visits. Adaptation includes the use of positive reinforcement and the Tell-Show-Do Technique to demonstrate procedures to the patient and caregiver. The consistent routine allows brushing at the same time and in the same location each day. Nurses can promote excellent oral hygiene through tailored strategies, such as implementing oral care using fluoride toothpaste with adapted tools, like a three-sided toothbrush and Ergonomic handles for better grip, as soon as the first tooth appears. This helps build a routine and positive association. Nurses should encourage regular dental checkups and teach parents how to effectively help their child with oral care.

Conclusion: Nurses can significantly impact health outcomes and quality of life by providing a comprehensive, patient-centred approach, which is essential for tailoring their practice effectively.

Keywords: Dental care in Down syndrome, Down Syndrome, Mouth care, Oral health care, Oral hygiene.

Postgraduate student poster abstracts

07 Barriers to oral health care for patients with Down syndrome – Solutions & strategies.

Ahana Sharma^1*, Natasha Gambhir²

¹Department of Pediatric & Preventive Dentistry, Santosh Dental College & Hospital, Ghaziabad, Delhi NCR, India.

²Department of Pediatric & Preventive Dentistry, Santosh Dental College & Hospital, Ghaziabad, Delhi NCR, India.

*E-mail: ahanas0206@gmail.com

Objective: To identify barriers to oral health care for children with DS and propose evidence-based strategies for improving accessibility and treatment outcomes.

Methods / Materials: A literature review and clinical case analysis were undertaken. Barriers were categorized as financial constraints, behavioral and sensory challenges, communication difficulties, provider inexperience, oral motor limitations, and associated medical comorbidities. Strategies were derived from current research and adapted for pediatric dental settings.

Results: Targeted interventions, including professional training in special-needs dentistry, sensory-adapted dental environments, patient-centered approaches, and caregiver education, improved cooperation and outcomes. Case evidence indicated sensory-adapted settings significantly reduced distress. Policy-level and systemic interventions were identified as crucial for achieving a sustainable impact.

Conclusion: Children with DS face significant barriers to oral health care. Holistic, integrated strategies—combining professional training, sensory adaptation, caregiver support, and systemic policy measures—can improve access, equity, and quality of life for individuals with DS.

08 Barrier-free smiles: Solutions and strategies for oral health care in Down syndrome

Roshani Subedi¹, Pratima Khadka¹

¹Department of Conservative Dentistry and Endodontics, National Academy of Medical Sciences, Kathmandu, Nepal.

roshanisubedi52@gmail.com

Objectives: This scoping review aimed to explore the existing literature about these barriers and to identify strategies to enhance dental care for this vulnerable population.

Methodology: A comprehensive search was conducted across PubMed, Scopus, and Web of Science, focusing on peer-reviewed studies published in English within the last 10 years that examined barriers and strategies related to patients with DS.

Results: These studies, published between 2015 and 2023, primarily employed cross-sectional designs and identified key barriers, including challenges in maintaining oral hygiene, limited access to specialised dental services, and behavioural and sensory difficulties that affect dental care for children with DS. Strategies to overcome these barriers include enhancing dental professional training, developing tailored care approaches, and integrating preventive dental programs into broader health initiatives.

Conclusion: By emphasising the need for enhanced dental professional training, personalised care approaches, and integrated preventive programs, this review provides a framework for improving dental care accessibility for this population. Addressing these barriers can lead to better oral health outcomes and improved overall well-being for children with DS.

Keywords: Barriers, Down syndrome, Dental care, Preventive strategies.

09 Interdisciplinary approach: Collaboration in dental and medical care for Down syndrome

Prajjwal Srivastava¹, Anvi Baranwal¹

¹Department of Pediatric Dentistry, Saraswati Dental College & Hospital, Lucknow, India.

prajsri.1698@gmail.com

Objectives: To highlight the importance of an interdisciplinary approach in providing comprehensive dental and medical care for individuals with Down syndrome.

Material and methods: The poster integrates evidence-based literature and clinical experiences to emphasise the collaborative roles of multiple healthcare professionals.

Conclusion: Effective management of individuals with Down syndrome requires a holistic, team-based approach involving dental and medical professionals. Such collaboration ensures individualised care, minimises procedural risks, and significantly improves oral health, overall well-being, and quality of life for these patients. Early interdisciplinary intervention remains the key to successful long-term outcomes.

Keywords: Down Syndrome, Interdisciplinary, Trisomy 21

10 Barriers to oral health care for patients with Down syndrome: Solutions and strategies

Bhavleen Kaur¹, Anjali Puri¹

¹Department of Conservative Dentistry and Endodontics, Punjab Government Dental College and Hospital, Amritsar, India.

drbhavleenbds@gmail.com

Objectives: The main aim is to explore the existing literature about these barriers in oral health care for patients with DS and to identify strategies to enhance dental care for this vulnerable population.

Material and methods: A comprehensive search was

conducted across PubMed, Scopus, and Web of Science, focusing on studies published within the last 10 years that examined barriers and strategies related to patients with DS. Data were extracted using a standardised form, analysed, and synthesised to identify and categorise barriers and strategies across studies.

Results: The search yielded 58 articles; after screening, 13 were considered for full-text review, and 6 met the inclusion criteria. Reported barriers included difficulty in maintaining oral hygiene, behavioural and sensory challenges, limited access to specialised dental services, insufficiently trained professionals, financial constraints, and geographic disparities. Strategies to overcome these barriers included enhancing dental professional training, developing tailored care approaches, educating parents and caregivers, and integrating preventive dental programs into broader health initiatives.

Conclusion: This review highlights significant, persistent barriers to dental care for children with DS. To overcome these barriers, there is a need for enhanced dental professional training, personalised care approaches, and integrated preventive programs. Implementing these strategies can enhance dental care access and contribute to improved overall health and well-being for children with DS.

Keywords: Barriers, Down syndrome, Dental care, Oral health access, Preventive strategies, Special needs dentistry.

11 Interdisciplinary approach: Solution of nodus

Tushar Bhargava¹

¹Department of Prosthodontics and Crown and Bridge, Army Dental Centre, New Delhi, India.

drtusharbhargava@gmail.com

Objective: To evaluate the effectiveness of an interdisciplinary approach integrating prosthodontics, behavioural management, and digital dentistry in the rehabilitation of patients with Autism Spectrum Disorder (ASD) and other special care needs.

Material and methods: A clinical study was conducted involving fifteen patients requiring prosthetic rehabilitation who presented with behavioural or cognitive challenges associated with ASD or congenital conditions. The cases described are : (1) fabrication of a spectacle-retained auricular stent for auricular defect rehabilitation, and (2) fabrication of a silicone glove prosthesis for congenital syndactyly. Simplified prosthesis designs, behaviour guidance, and appropriate digital planning were utilised to enhance patient cooperation and treatment precision.

Results: Post-rehabilitation evaluation demonstrated measurable improvements across multiple health domains, including aesthetic satisfaction (22%), physical efficiency (25%), psychological benefit (26%), and nutritional well-being (27%). Enhanced comfort, acceptance, and social reintegration were reported by both patients and caregivers.

Conclusion: The success of prosthodontic rehabilitation in patients with special care needs relies on interdisciplinary coordination, simplified and customised prosthetic design, and active participation from caregivers. Incorporating digital workflows facilitates precision and patient-centred outcomes. This holistic approach not only restores function and appearance but also improves psychological, social, and nutritional well-being, thereby enhancing overall quality of life.

Keywords: Autism spectrum disorder, Digital dentistry, Interdisciplinary care, Prosthetic special care needs, Prosthodontic rehabilitation, Quality of life.

12 Barriers to oral health care for patients with Down syndrome: Solutions and strategies

Sharanya A J¹

¹Department of Conservative Dentistry and Endodontics, King George’s Medical University, Lucknow, Uttar Pradesh, India.

sharanyajayachandra@gmail.com

Background: Children with Down syndrome (DS) often face unique challenges when it comes to their oral health. While they may have fewer dental cavities than other children, they are much more likely to experience gum problems such as gingivitis and periodontal disease. Unfortunately, getting the right dental care is not always easy. Families report barriers such as the high cost of treatment, limited insurance coverage, interruptions in care, and the behavioural or communication difficulties that can make dental visits stressful for both the child and the provider. Overcoming these barriers requires creativity, compassion, and teamwork. Gentle approaches, like behaviour management techniques, short “practice” or desensitisation visits, and, when necessary, sedation, can make dental treatment more manageable. Preventive care is especially important. Simple steps, such as fluoride varnish, customised oral hygiene routines, and caregiver training, can go a long way in protecting a child’s smile. At the same time, dentists and dental students need proper training to feel confident treating children with special needs. Involving schools and communities in awareness and support also helps families feel less isolated. Research indicates that the most effective outcomes occur when dentists, paediatricians, therapists, and caregivers collaborate. By focusing on prevention and inclusion, we can reduce the need for complex treatments and ensure that children with Down syndrome enjoy the same right to oral health as everyone else. Building more supportive policies and care models will help close the gap and create a future where every child’s smile is valued and protected.

Keywords: Behavioural management, Caregiver involvement, Down syndrome, Dental care barriers, Oral health, Preventive strategies.

13 Oral health challenges in Down syndrome: Genetic pathway–driven craniofacial changes and their impact on restorative and endodontic care

Tanvi Pimpale¹

¹Department of Conservative Dentistry and Endodontics, Saraswati Dental College and Hospital, Lucknow, Uttar Pradesh, India.

pimpaletanvi99@gmail.com

Objectives: To evaluate the craniofacial and dental manifestations in Down syndrome and analyse their implications for restorative and endodontic treatment protocols.

Material and methods: A narrative literature review was conducted using PubMed/Scopus/Google Scholar databases. Studies describing craniofacial anomalies, dental manifestations, and clinical management in Down syndrome were included.

Results: The review identified a higher prevalence of enamel hypoplasia (34–56%), microdontia (20–45%), and taurodontism (40–70%), along with frequent canal calcifications and obliterations, posing challenges in canal negotiation during endodontic management in individuals with Down Syndrome compared to the general population. Craniofacial anomalies such as midface hypoplasia, high-arched palate, and macroglossia were strongly linked to altered eruption patterns and malocclusion. Evidence suggests that these anomalies reduce the longevity of restorations and complicate endodontic access and instrumentation. Studies highlight the necessity of advanced imaging (CBCT), magnification, NiTi endodontic instruments, and adhesive restorative techniques to overcome these challenges.

Conclusion: Down syndrome patients present with craniofacial and dental anomalies that require early preventive interventions and customised clinical protocols. Anticipation of these challenges and adoption of evidence-based modifications enhance treatment predictability and long-term prognosis.

Keywords: Craniofacial Anomalies, Dental Manifestations, Down Syndrome, Endodontics, Evidence-Based Dentistry, Restorative Dentistry.

14 Interdisciplinary approach: Collaboration in dental and medical care for Down syndrome

Meenu Chhikara¹

¹Department of Conservative Dentistry and Endodontics, Saraswati Dental College and Hospital, Lucknow, Uttar Pradesh, India.

chhikara.meenu98@gmail.com

Objective: To highlight the importance of interdisciplinary collaboration in improving oral health, systemic outcomes, and quality of life in individuals with Down Syndrome.

Methods/Materials: A narrative review was conducted (2000–2025) using PubMed, Scopus, and Google Scholar. Peer-reviewed studies, systematic reviews, and clinical guidelines addressing interdisciplinary management of DS were analysed.

Results: Interdisciplinary care has demonstrated improved clinical outcomes, enhanced functional rehabilitation, and a higher quality of life. Dentists play a pivotal role in diagnosing and managing conditions such as eruption delays, hypodontia, malocclusion, and periodontal disease, as well as providing preventive care. Physicians address systemic co-morbidities such as congenital heart disease, hypothyroidism, diabetes, and recurrent infections. Collaborative teams comprising paediatricians, dentists, speech therapists, psychologists, and genetic counsellors offer comprehensive support. Innovative approaches, including molecular subtyping, CRISPR-Cas9 gene editing, hypoglossal nerve stimulation for sleep apnea, and drug trials (AEF0217), represent promising future directions.

Conclusion: Establishing multidisciplinary clinics, training in special care dentistry, and promoting caregiver education are key to achieving sustainable outcomes.

Keywords: Collaboration, Down Syndrome, Dentistry, Interdisciplinary care, Systemic health, Special care dentistry

15 Oral health challenges in Down syndrome: From childhood to adulthood – A review

Arun Singh¹, Abinia Vaishnavi¹

¹Department of Conservative Dentistry & Endodontics, King George’s Medical University, Lucknow, Uttar Pradesh, India.

arunsingh1894@gmail.com

Objectives: To review and summarise the oral health challenges faced by individuals with Down syndrome from childhood to adulthood, and to highlight stage-specific management and preventive strategies.

Material and Methods: A narrative review of the literature was conducted using databases such as PubMed, Scopus, and Google Scholar. Relevant studies addressing oral manifestations, disease prevalence, and management strategies in Down syndrome were analysed and categorised by age group.

Results: Children with DS commonly show delayed eruption and early gingival inflammation; adolescents often present with aggressive periodontitis and malocclusion, while adults face severe periodontal destruction, xerostomia, and prosthodontic challenges. Contributing factors include low immunity, comorbidities, poor hygiene, and limited access to dental care.

Conclusion: Oral health management in Down syndrome requires a lifelong, stage-specific, and multidisciplinary approach. Preventive programs, behaviour modification, and regular dental follow-up can significantly enhance oral function and quality of life.

Keywords: Down syndrome, Interdisciplinary management, Oral health, Periodontal disease, Preventive care.

Recommendations: Interprofessional, multidisciplinary, and collaborative care is the need of the hour for managing patients with special needs, as they often present with multiple health issues. An interprofessional approach should be incorporated into the curriculum from early career stages to help students understand the holistic management of patients, rather than adopting a compartmentalized approach.