Augmentative and Alternative Communication: What it is and when to use it

Augmentative and Alternative Communication is one of the most transformative areas of communication intervention. For many children, young people and adults, it's not just about “having a way to speak.” It's about being able to ask for help, make choices, refuse, play, learn, participate in a conversation, and show who you are.

When speech doesn't emerge, is unclear, is insufficient or has ceased to be functional, communication must not be put on hold. This is where Speech therapy it can play a decisive role, assessing the person's needs and choosing strategies that allow for better communication in daily life.

Augmentative and alternative communication, often called AAC, can include gestures, facial expressions, objects, photographs, symbols, communication boards, communication books, tablet apps or speech-generating devices. The aim is not to replace the person. It is to give them the means to express themselves with more autonomy, dignity and intention.

Comunicação Aumentativa e Alternativa (CAA) é um conjunto de estratégias e ferramentas para ajudar pessoas que têm dificuldades com a comunicação verbal.

Augmentative and alternative communication (AAC) is a set of strategies, methods, and resources used to support people who have difficulty communicating through speech. It can be used by children who have not yet developed functional spoken language, by adults who have lost their speech after a neurological injury, or by people who communicate orally but not sufficiently in all contexts.

The word “augmentative” means that the system comes to reinforce existing communication. For example, a child says a few words but uses symbols to build longer sentences or to make themselves understood when they are tired. The word “alternative” means that the system can function as the primary method of communication when speech is absent or non-functional.

In practice, AAC is not a one-size-fits-all tool. It's a system tailored to the individual. Some people use gestures and pictures. Others use a tablet with a communication app. Others combine speech, signs, expressions, writing, and technology. The central point is this: communication doesn't solely rely on spoken speech.

Augmentative and alternative communication is not giving up on speech

One of the biggest concerns for families is the thought that introducing AAC might make a child “give up on speaking.” This idea is understandable, but it doesn't reflect what clinical practice and research have shown. AAC does not reduce the motivation to communicate. On the contrary, it can reduce frustration, increase communicative initiative, and create more opportunities to use sounds, words, and phrases.

When a child can't say what they want, they often resort to crying, running away, tantrums, silence, or giving up. If we give them a clear way to communicate, they realise that communication works. They ask for more, comment more, choose more, respond more. And, when speech starts to emerge, it can be naturally integrated into the system.

Second A systematic review on AAC and speech production, interventions using augmentative and alternative communication do not prevent speech and, in many cases, can be associated with gains in oral production. This is especially important in children with autism, global developmental delay, speech motor difficulties, or other complex communication needs.

Quando usar comunicação aumentativa e alternativa?

Augmentative and alternative communication should be considered whenever there is a significant difference between what the person wants to communicate and what they can communicate effectively. There is no need to wait for a specific age, a definitive diagnosis, or years of failed attempts.

There are signs that warrant a specialist assessment. These signs don't mean the person will need a complex system, but they indicate that communication needs support:

• The child has few words for their age and becomes very frustrated when not understood.
• He mainly points, pulls the adult by the hand or cries to get what he wants.
• You understand more than you can express.
• Has speech that is difficult for family, teachers, or colleagues to understand.
• You can speak at home but freeze up in other situations.
• You have a neurological, motor, genetic, or neurodevelopmental condition that affects communication.
• Lost speech capabilities after a stroke, head injury, degenerative disease or surgery.

The sooner a person has a functional way to communicate, the more likely they are to participate in routines, learn vocabulary, build relationships, and reduce frustration-related behaviours.

Os benefícios da Comunicação Aumentativa e Alternativa (CAA) podem ser sentidos por qualquer pessoa que tenha dificuldades em falar, escrever ou compreender a linguagem verbal. Isto pode incluir pessoas com:* Condições neurológicas, como paralisia cerebral, esclerose múltipla, doença de Lou Gehrig (ELA) ou lesão cerebral traumática. * Dificuldades de desenvolvimento, como transtorno do espectro autista ou síndrome de Down. * Condições de saúde que afetam a voz, como câncer de laringe ou paralisia das cordas vocais. * Condições de aprendizagem ou dificuldades de comunicação. * Qualquer pessoa que, temporária ou permanentemente, não possa usar a fala para se comunicar de forma eficaz.A CAA pode ajudar essas pessoas a expressar suas necessidades, desejos, pensamentos e sentimentos, melhorando assim sua qualidade de vida, independência e participação na sociedade.

AAC can be useful at many stages of life. It doesn't just belong to autism, nor just to childhood. It's also not reserved for non-speaking people. Many speaking people may need communication support at specific moments, demanding environments, or in situations of greater fatigue.

Among the profiles that could benefit are:

• Children with Language delay slow communicative development.
• Children with autism spectrum disorder.
• People with cerebral palsy or motor impairments that make speech difficult.
• Children with childhood apraxia of speech, when the communicative intention is greater than the ability to articulate.
• People with Specific language impairment, when they need visual support to organise ideas.
• Adults with aphasia after a stroke or brain injury.
• Individuals with neurodegenerative diseases, such as ALS, advanced Parkinson's, or dementia.
• People temporarily unable to speak, for example in a hospital context.

The question shouldn't be “Does this person have a diagnosis to use AAC?”. The more useful question is: “Can this person communicate everything they need to, with whom they need to, in the contexts they live in?”.

Tipos de comunicação aumentativa e alternativa

AAC systems can be simple or technological. The choice should not depend on fashion, price, or the most well-known application. It should depend on the person's motor, sensory, cognitive, linguistic, emotional, and social abilities.

CAA without technology

This type of communication does not require external equipment. It can include natural gestures, facial expressions, eye gaze, pointing, manual signs, vocalisations and body movements. Often, these resources already exist before intervention, but they need to be recognised, organised and valued by the adults around.

Low-tech CAA

It includes simple physical materials such as photographs, cards, communication boards, choice boards, symbol books, visual calendars, and illustrated routines. These are accessible resources, easy to transport, and very useful at home, at school, during appointments, or in quick situations.

High-tech CAA

These include electronic devices, tablets with communication apps, speech-generating devices, adapted keyboards, eye-gaze access, switches or other selection methods. These systems can allow for more complex sentences, larger vocabularies, and communication in various environments.

A good system can combine these three levels. A person can use an app at school, a board in the bath, gestures at playtime and speech when they are able. Flexibility is one of the hallmarks of well-thought-out intervention.

How is assessment carried out in AAC?

The assessment should not begin with the question, “Which app are we going to buy?”. It should start with the person. The speech therapist observes how they communicate, with whom they communicate, where they communicate, what they are already able to do, and what barriers are limiting participation.

According to Specialist clinical guidance on augmentative and alternative communication, the assessment should consider speech, language, comprehension, motor, vision, hearing, literacy, family context, culture, preferences and functional goals.

A comprehensive assessment usually includes:

• spontaneous communication observation;
• analysis of language comprehension and expression;
• identification of current forms of communication;
• assessment of motor skills required for pointing, touching, looking or selecting;
• analysis of life contexts, such as home, school, work and community;
• involvement of family, educators, carers and other professionals;
• experimentation with different systems before making definitive decisions.

In childhood, this assessment can be part of a wider plan for Paediatric speech therapy, especially when there are difficulties with language, speech, social interaction, learning or school participation.

The role of family, school, and communication partners

An AAC system does not work on its own. Even the best device loses value if it's kept in a backpack, if it's only used during sessions, or if adults don't know how to wait, model and respond. Communication happens between people, not just between the person and the equipment.

Therefore, training communication partners is essential. Family members, teachers, assistants, peers, and caregivers need to learn how to create real opportunities to communicate. This includes waiting longer for a response, asking fewer closed questions, commenting more, accepting various forms of response, and using their own system while speaking.

Clinical guidance on AAC It highlights the importance of involving communication partners and adapting strategies to the individual's real-life contexts. Without this network, AAC might seem like it’s “not working,” when in reality, it hasn’t been given the opportunity to be integrated into daily life.

Here's how to start using AAC at home without turning everything into therapy:* **Start small and slow:** Don't try to introduce too many new symbols or concepts at once. Begin with a few core words that are relevant to your everyday activities, like "more," "eat," "drink," "play," or "help." * **Integrate it naturally into routines:** Look for opportunities to use the AAC system during existing activities. If you're eating, point to the "eat" symbol and say the word. If your child is playing, model using symbols for the toys they're interacting with. * **Focus on communication, not correction:** Your primary goal is to help your child communicate their needs and wants. Don't worry too much about perfect grammar or using the AAC system exactly how a therapist might at first. Celebrate any attempt to communicate. * **Model, model, model:** The best way for someone to learn to use an AAC system is to see it being used. Point to symbols and say the words yourself, even if your child isn't using them yet. This shows them how it works and what the symbols represent. * **Follow their lead:** Pay attention to what your child is interested in. If they're focused on a particular toy, use the AAC system to talk about that toy. This makes communication more motivating and meaningful. * **Keep it fun and engaging:** Use games, songs, or stories to incorporate AAC. The more enjoyable it is, the more likely they are to want to use it. * **Don't make it a test:** Avoid putting pressure on your child to "perform" or use the AAC system correctly. Frame it as a tool to help them share their thoughts and feelings. * **Involve the whole family:** If other family members are around, encourage them to learn and use the AAC system as well. This creates a supportive communication environment. * **Focus on what they can do:** Acknowledge and praise every attempt at communication, no matter how small. This builds confidence and encourages further use. * **Be patient and consistent:** Learning to use AAC takes time and practice. Consistency in your own modelling and encouragement is key.The aim is to make AAC a natural and helpful part of your daily life, allowing your child to express themselves more easily and reducing frustration for everyone.

The introduction of augmentative and alternative communication should be simple, natural, and repeated in real routines. There's no need to transform the house into a clinical room. The most important thing is to give meaning to the system.

Some initial strategies help to create consistency:

• Choose useful words, such as “more”, “want”, “no”, “help”, “finished”, “play”, “hurt” and “stop”.
• Utilise o sistema durante actividades motivadoras, como lanches, hora do banho, música, histórias ou jogos.
• Modelling without demanding, pointing to symbols while speaking.
• Accept any attempt at communication, even if it's not perfect.
• Avoid removing the system as punishment or making it available only at certain times.
• Celebrate the communicative intention before correcting the form.

if the family lives far from specialised services or needs regular guidance, the Online speech therapy can help train caregivers, adjust vocabulary, and monitor implementation in a natural context. In paediatric age, it may make sense to get to know online speech therapy for children, especially when parental involvement is central to the intervention.

Common mistakes that delay communication

Many difficulties in implementing AAC don't happen due to a lack of willingness. They happen due to a lack of knowledge, fear, or unrealistic expectations. Recognising these mistakes helps to avoid them.

• Wait for the child to speak first, even when they've been frustrated for a long time.
• Use the system only to request items, forgetting comments, feelings, choices and refusals.
• Choosing vocabulary that is too limited, which does not allow for varied messages to be constructed.
• Asking constant questions instead of creating natural conversations.
• Switching systems whenever difficulties arise, with no learning curve.
• Not involving the school, which prevents generalisation.
• To assume that a person who does not speak also does not understand.

This last error is particularly serious. The absence of speech should not be confused with the absence of thought, will or intelligence. A person may have a great deal to say and yet not have found the right means to express it.

CAA, emotions and social participation

Communication isn't just for asking for water or saying “yes” and “no”. It's for making friends, telling a funny story, protesting, asking questions, showing discomfort, saying you're tired, or choosing who you want to be with.

When a person is unable to communicate, they might withdraw, become overly dependent on others, or be misinterpreted. In some cases, prolonged communication difficulties can contribute to increased isolation, low self-esteem, and reduced social participation. Therefore, topics such as social distancing must also be considered in a global view of well-being.

Augmentative and alternative communication should open doors. It shouldn't limit a person to asking for basic needs. A well-constructed system includes vocabulary for affections, opinions, humour, pain, preferences, relationships, school, leisure and identity.

Sleep, attention and availability to communicate

Communication also depends on the body's state. A child or adult with fragmented sleep, extreme tiredness, pain, anxiety, or sensory overload may find it more difficult to use an AAC system. Not because they “don't know,” but because at that moment they don't have sufficient energy, attention, or regulation.

When there are signs of persistent tiredness, frequent awakenings, or daytime sleepiness, it can be helpful to look at your rest routine. Sleep deprivation It can affect attention, mood, learning, and willingness to interact, factors that also influence functional communication.

When to see a speech therapist?

You should seek assessment whenever communication is limiting autonomy, learning, relationships with others, or participation in daily activities. It is not necessary to wait for the problem to “resolve itself,” especially when frustration is already evident.

Seek support if the person:

• Unable to clearly express basic needs.;
• relies on others to guess what they want;
• avoids communicating for fear of not being understood;
• There are frustration behaviours associated with communication;
• uses few words, few gestures, or little communicative initiative;
• lost speech or language abilities;
• needs support to communicate at school, at work, or in healthcare.

A speech therapist doesn't just assess speech. They assess communication as a whole. And, where necessary, they liaise with occupational therapists, physiotherapists, doctors, psychologists, teachers, and family so that the system is accessible, functional, and sustainable.

Conclusion

Augmentative and alternative communication is not a last resort. It is a bridge. A bridge between intention and message, between person and world, between what is felt and what can finally be shared.

Waiting for speech may seem prudent, but for those unable to communicate, every day without means is a day with fewer choices, less participation, and more frustration. The most important question isn't whether AAC will replace speech. The question is how many communication opportunities the person is missing while waiting.

When properly assessed, well-chosen, and well-implemented, augmentative and alternative communication does not close off avenues. It opens up possibilities. And, for many families, this is the moment when communication ceases to be a daily struggle and becomes a clearer, freer, and more human relationship.