Tagged "Horn Hierarchy"

Ask A Therapist: Jaw Jutting

Posted by Deborah Grauzam on

Hi TalkTools,


How can I inhibit jaw jutting for Horn #1? We are working on the Bite Tube Set and establishing the natural bite with Bite Blocks but this child presents with frequent jaw slide or jaw jutting. Thanks,




Hi Anne,

I would provide firm jaw support to inhibit the jaw jutting. You can use jaw support for Horn #1 and Horn #2. Beginning with Horn #3 you would no longer provide jaw assistance.  I would be using the jaw support and gradually try to decrease use as the patient will tolerate. I hope this helps. Please let us know if you have any other questions.




Elizabeth Smithson, MSP, CCC-SLP is a Speech-Language Pathologist who has over 10 years of professional experience working with infants, children, adolescents and adults. She earned her Master of Speech Pathology at the University of South Carolina. Liz is also a Level 5 TalkTools® Trained Therapist. She has received specialized training in Oral Placement Therapy, Speech, Feeding, Apraxia, Sensory Processing Disorders, and PROMPT©. Liz works with clients with a wide range of disabilities including Cerebral Palsy, Down Syndrome, and Spinal Muscular Atrophy.  She works through her own private practice Elizabeth Smithson Therapy, LLC in the home setting and in the TalkTools® office in Charleston, SC.

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Ask A Therapist: 3 year old with Moebius Syndrome

Posted by Deborah Grauzam on

You all have been amazing when I have asked for help with my students, so I have another question. I have just evaluated a 3 ½ year old who was diagnosed at birth with Moebius Syndrome. Although I have had difficulty finding information about this syndrome, I managed to find an article Sara Rosenfeld-Johnson wrote that was extremely helpful and plan to follow her recommendations. My main concern right now is that a Haberman bottle was used to feed him, so now he clamps his teeth down on the flute and straw when I try to work with him. Is there any tool that is beneficial to inhibiting the teeth biting and promoting the normal suck and swallow and blowing? And if you have any other references for oral motor therapy related to damage to the 7th cranial nerve I would appreciate it. THANK YOU!!!!!!   Thank you for the compliment and the question.  I have worked with Sara and the Moebius population for the past 10 years and hope I can help with your question!


The clamping of the teeth is common since the primary problem we are working with is the inability to close the lips.  So this is very common with most of the children and adults we work with.  The key initially is to make the mouthpiece big enough to fit into the current lip opening.  To determine if this is even appropriate to begin, you need to know if the client has paralysis or paresis.  If you have seen any upper facial movement, flutters or twitches then you are looking at paresis and working on these skills may improve lip and cheek function.  Here is a basic outline of what you might do with straw and horn blowing; both a part of a complete oral placement program that would also address any deficits in jaw stability as you are trying to achieve lip from jaw dissociation (I can give you more information on that if you would like):

1st:  Begin by using the TalkTools vibrator and trimmed Toothette (the vibration is the key) under the upper lip and in the cheeks to provide sensation to the muscles. This would be done for 1-2 minutes and therapy activities would then follow.

2nd:  Horn Blowing:  Measure the lip opening when the child is in a resting lip posture, or if possible, trying to close his lips on command.  You may begin with Horn #1 if they have the breath support and skill but also may want to start with the Alex Tub Flute (TalkTools has begun carrying them but you will need to check availability).  This horn is easier to blow and has a wider mouthpiece.  If you use Horn #1, wrap the tip of the horn in medical tape several times until the mouthpiece measures the lip open position.  This will allow you to then support the jaw with your non-dominant hand and place the horn between the lips, rather than the teeth (the pre-requisite is that they know to exhale on command).  Using the TalkTools Progressive Jaw Closure Tubes is also helpful in teaching this skill.  As they meet the criteria, you can unwrap the horn mouthpiece one time and repeat until you have removed all the tape.  The lip, assuming there is the ability to gain movement will follow with practice.

3rd:  Straw drinking:  I would suggest starting with the Honey Bear with Flexible Straw.  There is a program Sara and I wrote several years ago called the Ice Sticks Program that has a technique using a syringe to teach a client to retract the tongue and swallow.  This same program can also be used with Moebius Syndrome with the goal of teaching the child to “slurp and swallow”.  You can use the Honey Bear following the same principles as the syringe technique to place the straw in the buccal cavity, squeeze and then tell the child to slurp.  You would need to ensure he is not biting on the straw (support with your non-dominant hand if needed) and that the tongue is retracted (you will often see the tongue protrude between the central incisors as an additional compensatory strategy if tongue retraction is difficult for them.  As they learn to “slurp” the liquid you have squeezed into the cheek, it activates the cheek, lip and tongue muscles, eventually leading to the child's ability to “slurp” the straw on their own.  There are several steps to teach this and I’m happy to share more detail if you need it as well!

I would also encourage you to visit the Moebius Foundation website.  Our past presentations should be available for you to view and may be helpful as well.

I hope this gets you started!  Clients with Moebius Syndrome are a joy to work with once you have the appropriate tools and starting point!  We’ve had great success with many individuals using these techniques!

Thank you,

Renee Roy Hill, MS, CCC-SLP

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Ask A Therapist: Thickened Textures, Straws & Horns

Posted by Deborah Grauzam on

Hello, I have some questions regarding your therapy tools/techniques:


1. Why is the goal to have 1/4 inch of the straw in the mouth for the straw hierarchy? Why does the length matter?


2. Do you work on the thickened textures program with the hierarchy straw program simultaneously or should they be done subsequently to the completion of one of the programs?


3. Where can you obtain nectar?


4. Many of the horns have the same type of mouth openings. What is the purpose of having multiple horns with the same type of openings - do they really target different sounds and oral motor postures?


Thanks for your help!




Dear Devorah,

Hi my name is Monica Purdy and I am a TalkTools® Instructor. I wanted to answer some of your questions.

1. The goal for having the straw 1/4 of an inch in the mouth is due to working on lip dissociation from jaw, and tongue dissociation from jaw. If clients are putting the straw on their tongue and are using 1/2 of an inch or an inch, they are probably suckling instead of using tongue retraction. Tongue retraction - especially back of tongue side spread (which is what straw #8 works on) - is important for co-articulation.

2. Once you get to straw #5, you can then begin to use the second straw hierarchy with thickened puree. Often you will be using both of these hierarchies simultaneously.

3. Nectar is the consistency of the puree. For example, use tomato juice. Remember you do not have to use tomato juice, but the consistency of tomato juice. You can also thicken any liquid using nectar packets.

4. The horns really do target different sounds. Some of the horns are flat mouthed horns but the child starts to work on lip dissociation, because the mouth piece becomes smaller and requires more lip tension to make the sound and an increase in tongue tension.

I hope this helps, if you have any additional questions please let me know.

Monica Purdy

Monica Purdy, MA, CCC-SLP has more than 14 years of professional experience specializing in helping children with special needs to communicate. Monica is PROMPT and SOS trained, familiar with sign language, and well-versed in the use of augmentative devices. She is the owner of Kids Abilities Pediatric Therapy Clinic in Indianapolis, IN. In addition to her private practice, Monica is a member of the TalkTools® speakers bureau and has been invited to speak at numerous conventions and seminars across the U.S. and internationally. She is a graduate of Ball State University.

Meet her!

January 29 - 30, 2016 - Oral Placement Therapy: Assessment & Program Plan Development - Middlesex, NJ

February 11 - 13, 2016 - 2016 ISHA Convention - Rosemont, IL

March 16 - 17, 2016 - Oral Placement Therapy: Assessment & Program Plan Development - Sacramento, CA

March 18 - 19, 2016 - Oral Placement Therapy: Assessment & Program Plan Development - San Diego, CA

April 7 - 10, 2016 - 2016 MSHA Convention - Osage Beach, MO

For more information and to register, visit our Event Calendar.

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Ask A Therapist: Horn #9

Posted by Deborah Grauzam on

Hello TalkTools,


I purchased the Horn Kit about a year ago, and the Horn #9 (airplane) in my kit does not have the propellers on it. My husband was informed via a recent email that they were taken off as a precaution because they could pose a choking hazard.


My son is now at this horn in the Horn Program, and his therapist is not sure how to assess whether he is doing this horn correctly without the propellers. With previous patients of hers, if both propellers spun, then she could tell the child was blowing hard enough/correctly. She is now not sure how to assess when my son is ready to move to the next horn, since the propellers are not there.


Can someone please tell us how to assess this horn correctly?


Thank you for your time!




Hi Brianna,

I'm Renee, a TalkTools® Instructor, and I would be happy to answer your question.

You are correct, the new horn #9 does not have propellers, but not to worry, the movement of the propeller is not the determining factor of duration.

What your therapist will want to do is “listen" for a 2-second blow that is steady and controlled using a stable jaw, cheek tension, lip protrusion and abdominal grading. Although the propellers added a “fun” factor, the goal is not to make them move. The movement of the propellers actually led to some clients trying to blow too hard, so I believe the removal of the propellers has really improved the horn!

I hope this helps!

Renee Roy Hill, MS, CCC-SLP

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Ask A Therapist: Client with Autism and Apraxia of Speech

Posted by Deborah Grauzam on

Hello TalkTools,


I am an SLP working with a four year old boy with autism and apraxia of speech. He has some significant drooling and is non-verbal. I completed the "Three-Part Treatment Plan for Oral Placement Therapy" on-demand course, but was hoping for some guidance from your Instructors.


He is the first child I've used Oral Placement Therapy (OPT) with, and we're working on the Drooling Remediation Program. He's progressing really well with the Chewy Tubes and the Straw Hierarchy but is not able to volitionally blow on Step 3 of the Bubble Blowing Hierarchy, nor is he able to blow for Horn #1 or hold a tongue depressor between his lips for any length of time.


He is able to produce the /m/ and /b/ sounds, but often not on command. He just recently began to show some lip rounding while producing a /w/ sound.


I did purchase the Pre-Hierarchy Horn and have been working on the ball/exhalation activities. Is there anything else I can/should be doing to help him with blowing?


Also, when he eats, he sometimes will chew the food, remove the bolus from his mouth, rest for a few seconds and then place the food back in his mouth and finish chewing/swallowing. Do you have suggestions on how to address this?


Thank you in advance,




Hi Amber,

I'm Robyn, a TalkTools® Instructor, and I will answer your questions the best I can without knowing the child.

I will start with the feeding issue first. This sounds like a self-stimulatory associated with the autism or an issue of bolus mobility. He certainly could have chewing fatigue, or perhaps cannot lateralize the bolus to where it needs to go to swallow it. You will need to assess this, and if needed, implement a pre-feeding program such as, Feeding Therapy: A Sensory-Motor Approach. If all is assessed and nothing is wrong from an oral motor perspective, I would work with the child's behaviorist on a regimented plan to keep his hands down and away from the mouth during feedings.

On to your OPT questions... Phonatory control and volitional blowing can be a very big problem with apraxia. The sounds the child is making can be reflexive in nature but not achievable on command. This is also a defining trait of apraxia. I would consult with OT/PT to start working on rib cage expansion, trunk stability, and core strength as prerequisites for blowing. For now, expose him to the Bubble Program staying on step 2 of the Bubble Hierarchy and practice placing Horn #1 in the mouth and taking it out for the lip closure motor plan. You may also model it for him with your own horn. I often sing, "If you are happy and you know it blow a horn toot toot" and place the horn in the lips when I say 'toot'. I also place children in a prone position on an OT wedge during this task. Immediately after drilling the horn, use the Apraxia Bilabial Shapes to practice the bilabials.

Good luck!


Robyn Merkel Walsh, MA, CCC-SLP

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