Adapting Clinical Practices for Neurodivergent Learners
Updated: Jul 16
As a behavioral voice specialist, my clients are more likely to be neurodivergent than neurotypical. These observations correlate with peer reports in our 4/4/22 Gender Voice Mastermind and decades of research. For example, in 2020 Warrier V. et al conducted a large scale study of 641,860 people that documented significantly elevated rates of neurodiversity in the transgender and gender diverse community.
Neurodiverse people are less likely to perceive social constructs such as gender, allowing them to be more receptive to exploring where they fall on the gender spectrum. This difference in perception may be part of why neurodiversity is more common in the gender diverse community. Regardless of the reason for the higher rates of neurodiversity, adapting your services is an excellent way to be an active ally to this vulnerable community.
While the below content is for informational purposes only and is not medical advice, I hope it is able to help you jumpstart your thought process on how to improve your practice.
TL;DR Neurodivergent learners process sensory information and interact with the world differently. Neurodivergence is present in many people, and is not necessarily pathological. Modifying your teaching and communication styles to play to your client's strengths and accommodate their differences facilitates learning. Some simple steps you can take are to prepare people ahead of time for what to expect, be respectful and encouraging to build trust, and be clear and concrete with your instructions. Many people are self-aware; ask how they learn best and what supports help them. Try that out, observing and following the client's lead, and adapt as needed. Below is a detailed list of strategies that will help you provide accessible, inclusive, efficient, and effective services for neurodivergent learners.
Special thanks to Hath Bierre for bringing their expertise as an autistic with lived experience changing their voice for editing the recommendations below.
What does it mean to be a neurodivergent learner?
Neurodivergent learners can have a wide array of differences in brain functioning from what's considered standards. They may process sensory information and interact with the world differently. While these differences are not necessarily pathological, they can effect mood, social skills, sensory sensitivity, learning style, attention, cognition, and concentration.
Modifying your teaching to play to someone's strengths and accommodate differences in learning and communication styles can make your services more accessible, and help instead of risking harm.
What falls under the neurodivergent learner umbrella?
Differences in brain functioning are present in a wide array of people. For example, stutterers have differences in their brain's motor speech pathways. Many of your clients may have one or more of these neurodivergences:
Autism
Motor speech disorders including stuttering/Disfluent speech, dyspraxia/apraxia of speech
Attention differences (ADD, ADHD) and their effects, such as rejection sensitive dysphoria (hyper sensitivity to criticism). Rejection sensitive dysphoria can also present with other types of neurodivergence as well, such as a trauma response.
Mood disorders and mental health illnesses/issues (bipolar, depression, anxiety, obsessive compulsive disorder/OCD, bulimia, anorexia, and other eating disorders, addiction, schizophrenia, dissociative identity disorder/DID, dissociation as part of survival strategy/masking, post-traumatic stress disorder/PTSD, social phobia, etc.)
Tourette's syndrome
Traumatic brain injuries (TBI)
Sensory processing disorders and differences, including hypo/hyper sensory sensitivity, synesthesia (joining/merging of senses that aren't normally connected), and aphantasia (cannot visually imagine)
Language processing disorders, including auditory processing disorders and dyslexia
Many neurodivergences have been clinically classified as disorders, but recent movements have begun within many of these communities to perceive them as differences, rather than disorders. While some neurodivergences are clearly not solely differences, such as traumatic brain injuries, others could be perceived as differences, such as autism. Consider interactions at geeky conferences where the neurotypical person is the odd one out, and the autistic people have no difficulties communicating with one another.
Help Neurodivergent Learners Succeed and Flourish
It takes time to get to know someone's interests, strengths and challenges- but students often come in self-aware. Therefore, the first step is to ask how they learn best! People are often self-aware of what helps them learn and be comfortable in their learning environment.
Step back and observe if information is better understood if presented in one modality versus another. For example, does your client prefer to have the slide explaining the concept up while you're teaching it, or just to see you?
Consider Criticism
Build a good foundation of trust first. Start with being respectful and encouraging. Once they're able to relax enough your constructive feedback can be considered without feeling like it is critical or judgmental.
Be aware that people with rejection sensitivity dysphoria or oppositional defiant disorder can be very sensitive to even small criticisms. Be aware of this sensitivity and work around it to make a world of difference, from preventing them from not being receptive to your feedback all the way to avoiding triggering a down-ward spiral.
Autism
For autistic people, be very clear, explicit and concrete, relying on words instead of body language and other nonverbal communication. This includes humor- someone may not realize when you're joking or using sarcasm. I've noticed teens in particular often have different senses of humor than me!
Present information in small chunks with sequential steps (also helpful for people with memory and attention challenges)
Explore why. Understanding why to do something is necessary for some people. Explain the reasoning, not just say do the thing. My autistic husband described punishment not working for him as a child- only explaining to him why something needed to be done a certain way would facilitate him making different choices.
Provide texts or videos before sessions with what to expect. This can go a long way towards reducing anxiety before starting working with a new professional. If this works for your client, you can also use visual schedules and follow routines during sessions so they can anticipate what to expect next.
Difficulty with or differences in eye contact are common- follow the client's lead, and don't assume a lack of eye contact means someone isn't listening.
Attention
Ask or observe what type of attention skills someone has. Some have racing thoughts where their thoughts move rapidly, while others are inattentive.
For people with attention differences, notice when their attention has wandered and consider which is most effective/needed: redirecting them back to the task, changing to a different task, following their lead and shifting to a new topic, taking a break, or ending the session early.
General Tips
Give extra time. Be comfortable with silence. I'm often delighted to hear what direction clients go in when I pause to give them time to process and direct the session.
Offer more repetitions, including restating concepts in different words.
Provide models.
Check for comprehension: Ask clients after teaching a concept to repeat back what they learned. At the end of the session ask the client what they learned throughout the entire session, and clarify any points they’re confused on, I find this to be especially helpful with teens.
Visual supports can be great for many, while for others they are challenging to access. If someone has trouble interpreting text, try presenting information in picture form. Make any visual materials you use accessible by increasing font size. If you're designing an online page, make the text accessible for screen readers and provide descriptions for pictures.
Provide visual/text/video explanations of the concepts taught in session, or a recording of the session for clients to review later. My clients with attention, reading, or writing challenges really appreciate when I email them my session notes home practice instructions.
Dialectical behavior therapy (DBT) may be helpful for anxiety in some neurodivergent learners, but may or may not be helpful for autistics. Teach mindfulness techniques in accessible ways.
Therapeutic and teaching interactions are relationships. Ask clients questions to invite them into the process along the way.
Determine what amount of information people want regarding science information. Some people love it, while others get overwhelmed.
Differences, Not Disorders
Make space for your client, their needs, their wants, and how they’re feeling that day.
Only work on what they've identified as their goals. You aren't there to fix everything, only what they wish to work on. If something appears abnormal but they're ok with, that's fine. Ask people what they want to work on, and be clear that we’re not in the driver’s seat.
Include Movement
Allow tics and unintentional or fidgety movements to occur without judgment.
If people have trouble sitting for long periods of time, try movement during or between activities.
Offer fidget toys or suggest a manual task such as folding laundry that can be done simultaneously to help with focusing.
Build Your Own Self-Awareness
Respect your own personal boundaries and refer out as needed. Some people work best with other people.
Be self-aware of your current physical and mental well being- some days it may be in the client’s best interest for you to reschedule.
Money and time are finite resources, and delaying improvement can be harmful. No one can be the expert on everything. If someone needs more expertise than you currently have, refer.
Continually educate yourself- it's easy for knowledge to become stagnant in the quickly evolving fields of transgender and gender diverse healthcare.
Shift Your Perspective
Find out what someone knows about themselves by talking less and being an active listener. This creates a safe space where the client can lead, and inspires trust in which they feel safe to express themselves in any way that feels good to them. Try not to impose too much on the setting to accommodate that. See narrative humility- learn about the person and what they need.
Avoid grouping people by diagnosis or symptoms. While labels can help you have a starting place and general idea how to help, everyone is different.
Be intentional when diagnosing. We know that naming things allows them to be known and controlled, continuing the status quo, and can be just as likely to harm as to help. Sometimes having a name for something can be helpful, while sometimes pathologizing differences makes everything a disorder. Some may view qualities as differences to adapt to, while others may perceive them as disorders they wish to overcome. To navigate this, allow clients to tell you how they self-identity.
Supports For Voice Training
Consider when to use guided meditation- it might not be the right tool when someone's nervous system is activated, or you don't know their triggers. Be aware that there isn’t a whole lot of agency in guided meditation. You need to know that they're in a good place for being in the body.
Train healthy breathing before using breath holding techniques.
Encourage clients to take care of themselves physically and mentally (hydration, sleep, decompressing).
Provide voice training in a quiet, low distraction environment.
Take interest in their interests- it may be easier to practice their voice when talking about a preferred topic.
Be sensitive to visual dysphoria by making the camera optional- it may be easier to talk/practice the voice without having to be seen on camera.
If the process requires clients to self-monitor or mask, voice training can create significant anxiety. Make space for discussing the way their voice or neurodivergence is affecting their life outside of voice training, even if how they’re expressing themselves isn’t falling into socially normative communication patterns. Providing a non-judgmental space where someone can express themselves as they're most comfortable doing can remove counterproductive restrictions and facilitate progress.
Ultimately, the steps you take to help neurodivergent learners flourish with you help all students! So start thinking today about how you can improve your practice to be more effective, inclusive, efficient, and accessible.
-Tallulah Breslin, MS, CCC/SLP
Gender & Identity Affirming Behavioral Voice Modification @Harmonic Speech Therapy
