Tagged "horn therapy"

Ask a Therapist: Significant Tongue Thrust Swallow Pattern and Tongue Protrusion

Posted by Deborah Grauzam on



I have a 13 month old with Down syndrome who has a significant tongue thrust swallow pattern and tongue protrusion. Her tongue is ALWAYS out of her mouth, far. Almost as if she is intentionally pushing it all the way out. She retracts her tongue when I place a straw in the corner of her mouth, place a puff on her molar ridge (and will maintain tongue lateralization for a short period), and when I place the elephant jiggler in her mouth. As soon as she attempts to control the puff with her tongue or swallow, her tongue pushes forward again. I can prompt her to retract her tongue at rest but it comes right back out. What else can I do? I only get to see her one time per month at this point. Mom sits in on sessions and carries over at home. Pediatrician and ENT have no concerns about size of tonsils; I have not observed them myself yet.




Hi Aubrie,

It sounds like you have been working really hard with this patient to address the tongue retraction.  Everything you are already doing sounds great.  I would add bubble blowing, horn blowing and chewing on the back molars (with cubes of food if able, z-vibe and the bite tubes). All of this will encourage tongue retraction in the mouth. The more you can work on the retraction the better.  

I hope this helps.

Please let me know if you have any other questions.


Elizabeth J. Smithson, M.S.P., CCC-SLP 


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.

Read more →

Ask A Therapist: Tongue Tip Elevation in Moebius syndrome

Posted by Deborah Grauzam on

When people need help with therapy or products, we put TalkTools® Instructors to work and then publish the exchange for anyone in the same situation to get help, too. This question is from Danielle, by Facebook message.


I was wondering if you could possibly help me. My six-year-old son has Moebius syndrome and recently had facial reanimation surgery. We have been doing TalkTools therapy for years and love it. We do a lot, from the Z-Vibe to Chewy Tubes to the horns! We have him try to follow the Z-Vibe with his tongue, but I can’t get his tongue to lift up. My question is: how can I help my son improve tongue movement? He has twelfth cranial nerve palsy, and his tongue has become so much stronger with therapy, but tongue tip elevation is still so hard for us. Any tips? Thanks so much for your help.


Hi Danielle,

Here are some questions that may help us think about why he may be having difficulty. When we are looking for tongue tip elevation we need to know first if he has jaw stability, tongue retraction and tongue tip lateralization skills first; these are prerequisite movements we look for. If you are unsure of any of the terminology let me know!

1. Does your son get any lateral movement? If so is he getting lateral movement to both sides? What activities do you see this movement in?

2. Can he chew on his back molars and hold the food there? Do you see his tongue move toward the food as he chews? Does this look easy for him?

3. Can he drink from a straw with tongue retraction? (Or does he protrude his tongue forward)

4. Have you done the Jaw Grading Bite Blocks so we know that he has adequate jaw stability as well?

If you’d like to send a quick video clip doing some stimulation of his tongue I may be able to see something.

All questions that may help us get a “why” answer and maybe a plan! Also, if you haven’t already, you should read this article by Sara Rosenfeld-Johnson about Moebius Syndrome. I look forward to hearing from you and helping any way I can!

Renee Roy Hill, MS, CCC-SLP

Thank you so much for replying, I appreciate it more than you know. My son does have some lateral movement, but it is limited. He uses his fingers so much to move his food to his back molars and has always been a messy eater. When he drinks from a straw his tongue protrudes forward as well. Thank you for taking the time to help us.


He still needs help with tongue retraction and lateral movement before working on elevation. He is not yet ready to work on elevation. Good luck with everything and let us know if you still need our help! 

Renee Roy Hill, MS, CCC-SLP

Renee Roy Hill, MS, CCC-SLP has provided therapeutic assessments and program planning for adults and children with oral placement, feeding and motor speech deficits for over 17 years. She is the owner of Crossroads Therapy Clinic in New Braunfels, TX and a member of the TalkTools® speakers bureau. Renee has been an invited speaker for ASHA state conventions and has received specialized training in speech/oral-motor/feeding therapy, Apraxia, sensory processing disorders, Hanen Courses, NDT training, TAMO therapy and PROMPT. She is the creator of the TalkTools® Schedule Board Kit, co-author of Ice Sticks, and author of the TalkTools® Apraxia Program.

Meet her!

  • February 10-11, 2017 in Pasadena, CA
  • February 23-25, 2017 in Austin, TX
  • March 3-4, 2017 in Mobile, AL
  • March 18-24, 2017 in the Caribbean
  • April 7, 2017 in Charlotte, NC
  • April 28-29, 2017 in New Orleans, LA
  • March 6-7, 2017 in Springfield, VA

For more details, visit TalkTools Event Calendar


Read more →

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

Read more →

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

Read more →

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

Read more →