I have been working with patients who have CAS for roughly 20 years, based on the DTTC strategies taught by the guru Edythe Strand. Over the years I have honed my skills, and continued my own educational journey related to CAS. When I start working with a new patient, I begin primarily by building trust. Kids oftentimes come to me after trying other therapy, without much success. Sometimes they have avoidance behaviors and significant frustration with failed communicative attempts. I demonstrate that I will ask them to do things that may be challenging, but it will be worthwhile; and we will be a wonderful team. You can almost see the moment when kids let down their armor and “give in” to the new process and therapeutic relationship.

Based on a thorough evaluation, we start treatment with sounds and word forms that are within the patient’s ability, with some level of support. We build up those words until they can be produced consistently and independently. As those words are being developed and practiced with high frequency, I am always looking for new words that are important in the child's life and that they may be stimulable for, to bring new sounds and words into the repertoire. This is not necessarily based on the typical progression of speech sound development. In any given session, I target about 7-10 words with many repetitions.

After many years of treating children with CAS, I feel like the treatment techniques have become something of an art-form. I adjust my level of support for each production the child makes. I adjust timing, pitch, and loudness to find the best way for the child to match the movements from one phoneme to the next. I generally do not focus on one phoneme at a time, rather the movement from sound to sound. I pay particular attention to the vowels and diphthongs, as these highly impact intelligibility. I do not teach approximations; I encourage accurate production on every trial. Other cues that I use, as needed, are tactile and visual prompts, for example manually helping the child squeeze his/her lips together, or using a pointing finger to highlight my lip movement for “b”. As word forms develop, these are built into longer, multisyllabic utterances - phrases, and sentences. I incorporate another CAS treatment strategy called REST and some phonological strategies when they become appropriate and necessary. Throughout treatment, I am regularly observing and addressing language (especially morphological development), phonological awareness/pre-reading skills, and pragmatic skills, as I find that these are critical areas which are often challenging for children with severely delayed speech due to CAS. In addition, signs, picture symbols and assistive technology are utilized to help the children successfully express themselves and continue building their language and social skills, while we are working towards more intelligible speech.