Tagged "Horn Hierarchy"

Ask A Therapist: Tips for Implementing the Horn Hierarchy

Posted by Deborah Grauzam on

Hello Talktools,


I'm a pediatric SLP with a clinical question for your experts. I attended the Three-Part Treatment Plan for Oral Placement Therapy (OPT) workshop last year. I have a little guy (3;4) who presents with low tone, has a breathy voice and speaks in short bursts.


I recently introduced the Horn Program, hoping that we could use it to improve his abdominal grading and breath support. However, we are having some problems with compensatory movements, and I'm having trouble remembering from the workshop what we are supposed to do about that!


When I hold up the horn, he leans, opens his mouth wide and reaches for it with his arms. If I can get him to sit back in the chair as I bring the horn to him, he inevitably opens his mouth wide. He also bites the horn for stability, and if I can get him to close his mouth as I present the horn, he grabs my shoulder for support.


I feel we need to back up, but I'm not sure where to go! Would one of the TalkTools® Instructors be able to help me with this? Do these sound like things his OT should work on? Are there some other activities you might recommend as a prerequisite for success with Horn #1?


Thank you in advance for any guidance on this issue.






Hi Kim,

This is a common problem when starting with a client, especially if he is just beginning an OPT program, has overall low tone and also has jaw instability and difficulty with lip-jaw dissociation. The aforementioned are all good reasons to use the TalkTools Horn Hierarchy. Following are some things to remember about using the Horn Program that may be helpful.

1. Consider your seating - Is he well supported with his head, pelvis, knees and ankles at 90 degrees? Does he have a place to rest his hands, head and feet? These are important to think about initially, remembering that what happens in the body often is seen in the mouth. If you do not have access to good support from a chair, try lying him down on the floor (I like a wedge if possible, but if you are working in a home you may only have access to a pillow). Gravity can help him with stabilizing the body, and if he’s not working against his own lack of support through his core muscles, you may get a better start.

2. It is absolutely OK to provide jaw support when starting out. If you remember, you can also progress forward through Horn #1 and #2, even if you are still needing to give him support. Jaw support can help and is crucial in eliminating a few of the problems you are reporting: Moving forward (you are providing stability at the lowest level of oral function and often need good support to start. Think about getting his body and jaw positioned first with your support and THEN present the horn. Doing both at once often leads to habitual compensatory movements), controlling the opening of the jaw (increase your support as needed until he opens just wide enough - if he still has difficulty, think about where you are in his Jaw Program. If you are just beginning and he has poor jaw control, this may not be something you can completely control just yet, working on a jaw program simultaneously- the TalkTools® Bite Tube Set and/or the TalkTools® Jaw Grading Bite Blocks will help! You may also want to consider supporting him from behind if his chair seems to be supporting him OK at the hips, knees and feet but he has nowhere for his hands or head to stabilize. In this case, you would use your body as the support from behind while wrapping your hand around the head to support the jaw. This can also eliminate some of the leaning forward you may see, especially if he is seeking stability/sensory input.

3. If you continue to struggle, consider backing up and working with Step B of the Bubble Blowing Program to teach him to control airflow; this is where you blow the bubble and catch it on the wand, having him use a voiceless “ha” to teach him to isolate the abdominals. This would take out the focus of lip closure and jaw stability for now, while teaching him to access volitional air with control. I’d also really consider your jaw program, and see if several sessions of jaw input might help you gain a little more control over his oral function.

All great questions and I hope these suggestions help you find a starting point. Of course if it leads to more questions, please don’t hesitate to contact us again!


Renee Roy Hill, MS, CCC-SLP

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Ask A Therapist: Horn Help

Posted by Deborah Grauzam on



I purchased the TalkTools Parent Kit back in December, and have been implementing the oral placement therapy with the support of my daughter's speech therapist since January.


We are making great progress with the straws and the bite tubes, but have hit a road block with the horns. My daughter, who will be two years old next month and has Down syndrome, is able to make a sound on Horn #1, but she also bites on the horn when she blows. As well, she sometimes uses her voice as well as blowing (sort of like a kazoo).


I'm not sure where to go from here.


Her speech therapist suggested stopping the horn hierarchy for a while and trying to get her to blow bubbles. I've tried blowing bubbles, and she can do it but isn't much interested. We've also taken a break from the horn, but any time I go back to it she does the same thing...although she's interested in the horn.


Please help! It is amazing what an improvement we've seen in such a short time. I know the horn hierarchy is an important component of what we're trying to do here, and I don't want to miss out on the benefits!


Thank you for the important work you are doing. I know my daughter is a bright, funny little girl. I want others to see what I see. Speech clarity and her appearance (tongue retraction) are critical to creating a positive first impression and breaking down negative stereotypes about people with Down syndrome.


Words cannot properly express the hope it gives me for her future to hear her speak clearly with confidence, when we were told she wouldn't be able to do that. Thank you for not accepting the status quo.  Thank you for using your expertise to help my little girl and others like her who needed someone to take the time to figure out the why and come up with the how.




Hi Jerilee,

Let me begin by saying how pleased I am that you are seeing such good progress in the short time you are using the Straw Hierarchy and the Bite-Tube Hierarchy with your two-year-old!

Your speech therapist's suggestion to go to bubble blowing was a good one, as it will establish the motor plan for blowing without making a vocal sound. Here is what I would suggest:

1. Have your daughter blow the bubble 1 time as you say "blow." Remove the bubble wand.

2. Place your non-dominant hand under her chin with your thumb against her lower jaw to keep her from biting on the horn.

3. Place the mouthpiece of the horn on her lower lip as you say "blow." Remove the horn, and if necessary, go back to the bubbles to establish the motor plan.

Thank you for your kind words about the work we are doing at TalkTools. Your comments about your daughter's emerging speech clarity put a smile on my face. Please let us know if you have any additional questions as you work through the program.

Sara Rosenfeld-Johnson, MS, CCC-SLP

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Ask A Therapist: Challenging Patient

Posted by Deborah Grauzam on

Hi TalkTools!


I have taken your Three-Part Treatment Plan for Oral Placement Therapy class and have 3 of your books. I am using OPT within my practice and see positive results in my patients. I do have one patient who is very challenging. She is 16 years old, globally delayed and has a diagnosis of cerebral palsy, sensory processing disorder, low cognition and is nonverbal. She loves to eat and does eat a fairly typical diet despite all of this, but of course, can't chew very tough meats. She drools. She has had very little oral motor therapy integrated into her speech therapy treatment plan over the years.


I will call my patient, M. We have been working on the bite tube hierarchy following the OPT evaluation, and she is able to compress the bite tubes (red bite tube- 10, bilaterally which is an improvement from where she started;  yellow bite tube- 7 on left and 5 on right- both sides of jaw are weak, but right is weaker). We are about to add purple bite tube when parent is ready. It has also resulted in less mouthing of objects, oral seeking and general calming.


M. is hypersensitive to facial touch and having her hair touched. She is also over responsive to some kinds of touch within the mouth despite use of sensory techniques from OPT (sensory program with toothette) and Beckman techniques used for several months. She has shown an improvement to tolerate tooth brushing at home since intervention.


1 - M. is using straw #1 on the straw hierarchy, but since it has been systematically cut to 1/4 inch, she is showing an increased jaw movement, which I'm thinking means she is still suckling the straw rather than using a true suck. She is getting better at not placing her lips over built in lip block. She only uses the straw for part of the evening at home with parent supervision, it is not used during the school day, but I might be able to arrange this with school staff. Do you think the reason she is not progressing on straws is that I have cut the straw too short, too soon, or is she just not getting enough practice with it? She likely has been suckling for many years now.


2 - I have not had any success using the bubble blowing hierarchy or horn hierarchy or pre-hierarchy horn, even with having a PT present to assist with positioning. She does not appear to understand how to grade her abdominal movements to exhale at all.


3 - I would appreciate any guidance you can give me regarding M., as I do want to help her with saliva control. We have had some success increasing her ability to request preferred snacks and activities with the PECS program, since she came to me with no communication system at all. I am about to visit her school to collaborate on her treatment program. Her parents are willing to work on PECS with her at home. They would like for her drooling to decrease, but they are only able to work on straws and bite tubes to a limited degree at home.


Thank you for your time.




Hi Holly,

Thanks for your question! Allow me to address each of your questions individually to make things easy to follow.

1 - Go back to the 1/2" length to see if she is moving her jaw.  If not, then go to 3/8" as she is 16 years old and may need that amount of the straw to give her enough room to protrude her lips.  The length is not as important as her ability to use only her lips with her tongue retracted and not biting on the straw.  If she can do that without jaw movement, progress to Straw #2 cut to 3/8".

2 - Try working with an OT who can bounce her on a ball to generate airflow.  Once she can do that, you can put the horn in her mouth as she is bouncing down to teach the relationship.  I have also described another technique below that I use with some kids.

Whispered “Huh”

Place the open palm of M's hand 1” in front of your mouth as you say a whispered “huh” sound.  Immediately place M's​ open palm in front of M's​ mouth as you model the whispered “huh” sound.  Continue to alternate between your mouth and M's​ mouth until M tires, refuses the intervention or produces a volitional exhalation.  Reward any attempt at imitation. (Goal:  Associate the feel of airflow on M's​ hand with volitionally controlled oral airflow for speech sound production)

3 - ​It sounds as though you are on the right track with this young girl.  Keep at it as the techniques you are suggesting are the correct ones and you are making progress.  Let the parents know that the horn blowing will be the best treatment for the drooling but that you need them to do the homework at least 3 times a week or it will not work. I hope this answers your question but if not, please let me know how else I can help.

Sara Rosenfeld-Johnson, MS, CCC-SLP

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Ask a Therapist: Vent Weaning with the Horn Hierarchy

Posted by Deborah Grauzam on

Hi Sara,


I attended one of your conferences in April.  I typically work with preschoolers with speech motor issues.  But my question is actually about a teenage boy on a ventilator.   Because it is not something that I typically do I didn't think of this sooner, but what I am wondering is if you have done any kind of vent weaning with your horn kits.  I know you talked about how they help with strengthening muscles for breathing and grading of airflow.


I'm asking because one of my friend's son was in a swimming accident 1 year ago.  He has a spinal cord injury and has been on a vent for a year.  He had surgery done in July to graft intercostal nerves to the phrenic nerve and from the vagus nerve to the phrenic nerve.  The idea was to see if new connections into the phrenic nerve would make it possible for him to be weaned from the vent.  Apparently the surgery was successful and the connections have formed and are good.  However, weaning someone who has been on a vent for a year is a big challenge.  Again not something I have much experience with but wondered if you have done any work or studies specifically regarding this issue.


I would love to try to help this boy and the family.  He was 18 at the time of the accident.  He had just graduated from high school and 2 months had the accident.  The injury was actually a C6-C7. He was not initially on a ventilator and could move his arms.   But due to a number of issues, the surgery to stabilize his spine wasn't done until 3 days after the accident.  This caused further damage up to C2.  Now he is paralyzed from the neck down and on a vent.  We are trying to get him to buy in to trying to wean which of course will be incredibly hard work on his part.  I am just looking for anything to guide or help in any way possible.


I appreciate any information you may have that could help me, even if it is to pass along information to the family.


Thank you!


I have worked with kids and adults who were initially on a vent and then weaned but I cannot say if the horns did it or it was just spontaneous recovery.  My gut feeling is that the horn and bubble blowing helped but again cannot say that for sure.  Here is what I would do.  First get approval from the doctor to use the two techniques.  If the boy does not have a valve to block the air then that will be your first hurdle.  Once a blockage is achieved (there are many options) have him blow the horn or the bubble 1 time, open the valve and let him breath.  Transition between these tasks working only while he is relaxed and comfortable with what you are doing.  As skills are mastered increase in the number of blows following the instructions that come with the horn kit.  The horns will help him to see progress in duration so may be a big motivator and assurance that he is making progress towards the goal of weaning him from the vent.  

I hope this helps.  

Sara Rosenfeld-Johnson, MS, CCC-SLP

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Ask a Therapist: OPT with Adult suffering from MSA

Posted by Deborah Grauzam on

Adult Speech Therapy


I am a trained speech-language pathologist, working in Sweden. I have taken part of the video-based course in the OPT-method and have very positive experiences from using the program with my former clients in a children’s rehabilitation center.

Now I work with elderly patients, primarily suffering from stroke but also with a wide spectra of neurological diseases.

This week, I met with a patient suffering from syndrome MSA, earlier misdiagnosed as Parkinson's. My colleague have worked with his dysarthria inspired by the Lee Silverman-method, which had a mildly effect on his difficulties with controlling the airflow. I proposed that we should try the instruments from OPT as a complement which the patient felt very positive about.

Though the patient recently started to experience difficulties with chewing food I wonder if it would be appropriate to work with the bite-tubes? We are all aware that his condition will continue to progress and that he most likely will suffer from dysphagia, not far from now. What are your thoughts about training when the patient have a progressive disease?

Best regards

Hi, Your email was referred to me for a response as I have been using OPT with adults for many years and have seen significant progress in both stagnate conditions and degenerative conditions such as MSA.  I am so pleased you see the benefits of this work and encourage you to continue to implement the techniques with your adult clients.

As a matter of fact I have just completed my newest book on using OPT with adults and am hoping it will be available for purchase within the next 6 months.    
In the case of a degenerative disease the hierarchy of intervention would remain the same as would the criteria for success to progress to the next level in each activity.  The major change is that your goal will be to maintain function rather than to improve function.  That is not to say in the initial phase of the disease the client will not progress but as the disease progresses the gain will become first minimal, then only maintaining and finally reducing.  
As you are working with these clients be aware of their fatigue and do not push them higher than their highest level before failure in each activity during the therapy session or for daily practice.  
You mentioned you are using the Bite-Tubes and that is wonderful.  I would also suggest the Horn Blowing Hierarchy and the Straw Drinking Hierarchy if the client is approved for thin liquids such as water or juice.  You can begin the Straw Hierarchy with liquids and if the client develops a pharyngeal phase dysphagia you can continue to use the Straw Hierarchy without liquid.  Instead use twenty 1 inch cubes of paper.  Have the client use the designated straw to pick up the piece of paper, to hold it for 10 seconds and then to rotate the head to drop the paper.  Remember to rotate to alternating sides of the body to ensure symmetrical muscle involvement. This technique has proven to be very beneficial for clients as a maintenance activity as the disease progresses.  
I hope this has answered your question but if not please feel free to email me.  
PS:  I loved my time in Sweden and hope to return there some day to teach and visit with friends.       
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