Signing, pictures or an AAC app: which suits your child?

What are the main types of AAC?

AAC (augmentative and alternative communication) is any way of communicating that adds to speech or replaces it. The Royal College of Speech and Language Therapists (RCSLT) says it can be unaided, such as signing, or aided: paper-based, such as boards and books, or powered, such as tablets and dedicated communication aids (RCSLT AAC position statement, May 2024).

The options can work together: Makaton combines signs and symbols with speech (Makaton Charity).

Which option suits my child?

There is no single right answer, and you don't have to pick just one. The RCSLT says "all types of system should be on offer to any potential AAC user" (RCSLT, May 2024). Talk it through with your child's speech and language therapist and think about:

• What nursery or school uses. Key word signing only works as communication if the people around the child understand it and use it too (O'Leary, Lyons and Frizelle 2025).
• Your child's hands. Signs need fine motor skills, and in a large US dataset 87% of autistic children were at risk of motor difficulties (Bhat 2021). Pointing or tapping may be easier.
• Who needs to understand. A picture with the word written on it, or a spoken word from an app, can be understood by anyone, not only people who know the signs.
• Whether your child talks. Children who talk can still use AAC. The RCSLT says anyone whose communication difficulties are "significantly impacting their quality of life" should be considered for it (RCSLT, May 2024).

Key word signing is not British Sign Language (BSL). BSL is a full language, recognised in law as a language of England, Wales and Scotland (British Sign Language Act 2022). If your child or a parent is Deaf, BSL is a language choice in its own right.

What does the research say about each option?

The main finding is reassuring: AAC does not stop children talking, though most studies are small. A review of the best studies found that none of the 27 people studied lost speech, and 89% gained some, though mostly modestly (Millar, Light and Schlosser 2006). A review of studies with autistic children agreed that AAC does "not impede speech production" (Schlosser and Wendt 2008).

• Key word signing. In one small study, three autistic pre-school children learned to sign, and their spoken words stayed the same or increased; the authors called this "preliminary evidence" (Tan et al. 2014). We found no controlled trials of Makaton or Signalong with autistic children. A study with three families found that signing takes effort to keep going (Cruz Leon and Zorn 2025).
• Picture exchange. PECS, developed in 1985, teaches communication with pictures in six phases, from handing over a single picture to building sentences and commenting (PECS UK). In a UK school trial with 84 children aged 4 to 11, gains were "not maintained 10 months later" (Brignell et al. 2018, Cochrane; Howlin et al. 2007). The developer's figure that 76% of PECS users acquire speech is its own claim, not an independent finding (PECS UK). PECS® is a registered trademark of Pyramid Group Management, LLC.
• Apps and devices that speak. In a trial with 61 minimally speaking children aged 5 to 8, starting with a speech-generating device led to more spontaneous communication than therapy using speech alone, even when only spoken words were counted (Kasari et al. 2014). In a trial with 68 children aged 3 to 5, a device plus coaching for caregivers improved joint attention straight away, and social communication four months later (Hampton, Kaiser and Fuller 2020).
• Adults modelling. A meta-analysis of 28 studies found that adults pointing to symbols as they talk, called aided language modelling, was "highly effective" across ages, disabilities and language levels (O'Neill, Light and Pope 2018).

How do I model on my child's AAC?

Modelling means using your child's system yourself as you talk: tapping words on their board, book or app, or signing key words. AssistiveWare, which makes AAC apps, says any modelling is better than none (AssistiveWare).

On a board, book or app

1. Keep it with your child all day. Communication should be available "at all times", so never take it away as a punishment or use it as a reward (Communication Bill of Rights; AssistiveWare).
2. Pick 2 or 3 words for the week, such as "more", "stop", "go" or "look" (AssistiveWare).
3. Point as you talk. Say the whole sentence and tap the key word: "Let's GO to the park."
4. Go one step beyond your child. If they use one picture, you use two (Binger and Light 2007).
5. Don't ask your child to copy you. They do not have to repeat the words you model (AssistiveWare).
6. Pause and wait, for up to 10 seconds, so your child can take a turn (O'Neill et al. 2018; Hanen: Waiting).
7. Answer every message, including "no", "stop" and "all done", as if your child had said it aloud (Communication Bill of Rights).
8. Model more than requests. Show comments ("look", "funny"), feelings and questions too. Most AAC research has focused on asking for things (Logan et al. 2017), but children need other reasons to communicate.
9. Expect it to take time. You may need to model a word many times before your child uses it (AssistiveWare).

With signs

1. Learn the same system as nursery or school, Makaton or Signalong (O'Leary et al. 2025).
2. Start with a handful of signs for words that matter now, such as more, finished, help and drink.
3. Sign the key word while you say the whole sentence, in normal word order (Makaton Charity).
4. Accept your child's own version of a sign as a real message, and sign it back clearly.

How do I get AAC through the NHS?

Start with your local NHS children's speech and language therapy service. Communication Matters, the UK charity for AAC, says this "is generally the place to start", and if you don't have one, to ask your GP for a referral (Communication Matters: Assessment).

• Most AAC support is local. In its 2016 service specification, NHS England expects local teams to manage "90% of the region's AAC population", with specialised services for the 10% who need powered aids or a specialist assessment (NHS England AAC service specification, 2016).
• Families cannot refer to specialised services. Referrals must come from registered health, education or social care professionals, and equipment is lent "as a long term loan", with yearly maintenance (NHS England, 2016). One service says it cannot accept referrals from "individuals, family members or independent therapists", and that acceptance "does not guarantee that AAC equipment will be provided" (Ace Centre).
• The 2025 criteria are about equipment. A person must have "significant difficulty communicating through speech", show "demonstrable communicative intent", understand noticeably more language than they can say, and have tried low-tech options first (NHS England specialised AAC eligibility criteria, 2025).
• Independent assessment is an option where local expertise is lacking or funding is available. Communication Matters suggests asking providers about their experience of AAC assessments and of children with similar needs (Communication Matters).

How much does AAC cost, and who pays?

Signs and paper boards cost little or nothing. App and device prices vary a lot, and funding depends on where you live and what your child needs.

• App prices. On the UK App Store on 28 September 2026, Twinkl Symbols AAC System was free (App Store), Widgit Go cost £59.99 (App Store), Proloquo2Go £249.99 (App Store) and LAMP Words for Life £299.99 (App Store), with a free "Discover" version (App Store). Some, such as Avaz, are free to download but offer paid subscriptions (App Store). Cboard is a free, open-source AAC web app (Cboard).
• Naming an app is not a recommendation. We have not tested these apps, and the right one depends on your child, so ask your speech and language therapist first. CALL Scotland, part of the University of Edinburgh, publishes a poster of iPad AAC apps chosen for their features, ease of use, reliability and developer support (CALL Scotland).
• Before you buy, check that you can back up the set-up, whether it works offline, what its App Store privacy label says, and that words stay in the same place as the vocabulary grows. Fixed positions helped young children find words faster in one study, though the children were not autistic (Thistle et al. 2018).
• Who pays. If a person meets NHS England's criteria, a specialised service "may lend that system to the person on a long-term basis". Schools and local education authorities can fund equipment, but then "it is typically considered to belong to the education provider" (Cambridge University Hospitals), so ask whether it can come home. Individual Funding Requests exist for exceptional cases, and some charities help, including the Sequal Trust and Communication Matters, which runs small grants (Communication Matters).

What are the common myths about AAC?

• "AAC is a last resort." The RCSLT says "early adoption of AAC can assist young children to develop cognitive, language, communication and literacy skills to their full potential" (RCSLT, May 2024).
• "AAC is only for children who can't talk at all." AssistiveWare points to the "space between not being able to speak at all and being able to meet all of our communication needs" through speech (AssistiveWare: Busting AAC myths).
• "A talking app is just more screen time." The expert group behind England's March 2026 screen time guidance for under-5s says its limits "do not apply to screen-based assistive technologies for children with SEND", and it names AAC (Early Years Screen Time Advisory Group). Games and videos on the same tablet still count.
• "Guiding a child's hand helps them communicate." Facilitated communication, where another person physically supports someone's hand or arm while they point or type, is not modelling. The RCSLT calls it a "discredited technique that should not be used in any circumstance" (RCSLT).

Where can I get more help?

• Your local children's speech and language therapy service, and your child's nursery or school SENCO.
• Communication Matters, the UK charity for AAC, offers people who use AAC and their families a free first year of membership (Communication Matters).
• The Makaton Charity offers an app and a digital learning kit (Makaton Charity), and Signalong, a key word signing system based on BSL, has a "Find a Signalong Tutor" service (Signalong).
• ASLTIP lists independent speech and language therapists, and Contact runs a helpline for families with disabled children.

Our guide Will my autistic child talk? covers everyday ways to support communication, and visual supports explains picture schedules and Now and Next boards.