Unfortunately, sometimes children who stutter also have other diagnoses, such as a cognitive impairment or Down Syndrome. In such cases, it is likely that more advanced forms of therapy (like making changes in speech to enhance fluency) are going to be too difficult for the child to maintain independently. (Such tasks are even difficult for typically developing students!)
As a result, clinicians will need to select therapy strategies that are clear and concrete, and that may put some common goals of therapy out-of-reach for some of our clients. Still, that does not mean that there is nothing we can do!
For those with cognitive impairment, it is often the case that their stuttering behaviors can be quite severe—lots of physical tension and struggle—as if they are responding to the feeling of being stuck by pushing as hard as they can. It is unfortunate, because communicating is already hard enough for such individuals.
If there is any silver lining to this difficult situation, however, it is the fact that one of the most concrete aspects of therapy involves differentiating between higher and lower levels of physical tension. Such differentiation is fundamental for strategies such as easier stuttering and for stuttering modification strategies. Thus, one of the treatment goals I typically consider is helping clients learn to stutter with less physical tension. (Note that this is not meant to exclude other aspects of therapy, but focusing on fluency may be quite difficult given the other issues.)
I often start this process with non-speech activities designed to help the student learn the difference between more tension and less tension. For example, we can take turns making tighter fists or looser fists, tighter arm muscles or looser arm muscles. I like to play around with increasing and decreasing physical tension while doing common tasks like walking, coloring, or shooting a basket.
If the student is able to grasp that difference, then we can work toward helping him experience the difference between more tense and less tense muscles during speech. We can practice trying to talk with our muscles more tight (using pseudostuttering, for example) and then practice talking with our muscles less tight. We can add to this specific practice using voluntary easy moments of stuttering in an attempt to reduce the overall physical tension in the speech muscles.
The overall goal is to help the student communicate more easily, even if he is still stuttering, because the moments of stuttering will be less disruptive to his communication overall.
Another aspect of therapy that will be very important for students with cognitive differences is the development of healthy, appropriate attitudes toward their communication skills. Students with cognitive impairment are always going to be different from other kids, and they need to know that it is okay to be different. It’s okay to have different abilities—it’s okay to look different and even to sound different. It is okay to stutter.
The more they learn that, the easier it is for them to accept themselves, and the less likely they are to tense and struggle as they try to hide their stuttering from the world. This is actually true for all children who stutter, but the need becomes particularly acute when the child has other differences that may make it harder for him to access some of the more complicated aspects of stuttering therapy.