Augmentative or alternative

Also called Augmentative communication, Alternative communication

The two halves of the acronym mean different things, and the difference matters most to a person who has some speech.

What it is

Augmentative communication adds to speech a person already has. Alternative communication stands in for speech that isn't there, or isn't there reliably. The acronym AAC bundles them, which is convenient, but they describe two quite different jobs.

A man with dysarthria after a stroke who is understood by his wife and not by the pharmacist needs augmentation: something to fall back on when the listener fails. A child with no functional speech needs an alternative: a primary way of saying everything. The tools might be identical. The purpose isn't.

Who it can help

The distinction earns its keep for people who have some speech. They are the ones most often told, wrongly, that AAC is not for them because "they can talk". A person with dysarthria, a stammer, a quiet voice from Parkinson's, or speech that goes when they are tired, anxious or in pain, is a candidate for augmentative communication, and the augmentation may be as small as an alphabet board to point to the first letter of a word.

For a non-speaking person the word alternative is the honest one, and it should be said plainly. Calling a primary voice "augmentative" understates what is at stake.

How it works

Augmentation usually works by repair. The person speaks first; when the listener doesn't get it, the aid comes out. So augmentative tools need to be fast, always to hand and easy to abandon once the message lands: a card in a pocket, a phrase on a phone, the first letter spelled out. See repair strategies.

Alternative communication has to carry the whole conversation, so it needs a full vocabulary, a way to build new sentences, and a route to literacy. A core board and a speech-generating device are built for this; a single card of phrases is not.

Most people sit between the two and move along the line through a day, or a decade. Someone with motor neurone disease may start with augmentation and end with an alternative, which is why planning early, including voice banking, matters.

Getting started

Work out which job you are doing. Ask the person, or watch: when does speech fail, with whom, and about what? If the answer is "in the pharmacy, with strangers, about medicines", you need a small, fast augmentative tool for that situation, not a full device.

If speech isn't doing the main job, stop waiting for it to and build the alternative now. Speech can carry on developing alongside; the two are not in competition.

Say the word out loud in meetings. "This is alternative communication, it is her voice, and it goes everywhere she goes." It changes how a ward or a classroom treats the device.

Where to get help

A speech and language therapist will make the call about which job the AAC is doing and pick tools to match. Communication Matters explains the terms for families. For stammering specifically, STAMMA can talk through when a tool helps and when it gets in the way.