10-Minute Speech Practice That Doesn't Require Sitting Still

Last updated 2026-07-11

What is the communication hierarchy for AAC users?

The communication hierarchy is a framework that organizes every possible way a person can send a message, from a raised eyebrow to a high-tech speech-generating device. It comes out of the broader field of augmentative and alternative communication, which the American Speech-Language-Hearing Association defines as "all forms of communication (other than oral speech) used to express thoughts, needs, wants, and ideas" ^[1]. The hierarchy does not rank these forms by value. It maps them by the tools they require, the contexts they fit best, and how much support they need from another person.

Speech-language pathologists use this framework to make sure an AAC user never has a communication gap. A device battery dies. A room gets too noisy. A partner does not know the symbol system. When one method fails, another is already in place. That backup thinking is the real point of the hierarchy.

The framework is often described in five general levels, though some SLPs collapse or expand these depending on the individual. What they all share is the idea that a complete AAC system is multimodal: it draws on several levels at once, more than one device or one board. The ASHA Technical Report on AAC (2004) stated that "individuals who require AAC rarely rely on a single technique or symbol set" ^[1]. That sentence is the whole philosophy in one line.

What are the five levels of the AAC communication hierarchy?

Here is how the five levels are typically described. Terminology varies between researchers and clinicians. What follows reflects the most widely cited version.

Level 1: Natural unaided communication This is everything the body does without any external tool. Facial expressions, eye gaze, gestures, pointing, head nods, vocalizations, and any speech sounds a person produces fall here. These methods are always available and require no equipment. For many AAC users, natural unaided communication carries enormous meaning that partners need to learn to read accurately.

Level 2: Partner-assisted symbol communication (unaided, externally supported) This includes methods where another person holds up or presents the symbols. Eye gaze frames and partner-assisted scanning both live here. The AAC user still uses their body (eye gaze, slight movement) but depends on a trained partner to make the system work.

Level 3: Low-tech aided communication Paper-based symbol boards, PECS binders, communication books, and alphabet boards are low-tech aided tools. They have no battery, no app, no screen. They are durable, cheap, and can be customized instantly with a printer and laminator. Many families rely on these as their primary or backup system.

Level 4: Mid-tech aided communication Recorded-voice single-message devices (like a BigMack button), simple sequencers, and basic static-display speech-output devices sit here. They require batteries and some programming but are far simpler than dynamic display devices. They are often the right starting point for young children or individuals who are still learning cause-and-effect.

Level 5: High-tech aided communication Dynamic-display speech-generating devices (SGDs) and full-featured AAC apps on tablets belong here. These systems can hold thousands of symbols, generate novel sentences, and produce synthesized or digitized speech. They are powerful but also the most expensive and the most vulnerable to breakage or battery failure.

A well-designed AAC system gives the user a real option at every level. The device gets left on the bus. The low-tech board is in the bag. The gestures are always there.

Why does the hierarchy matter for a child's AAC system?

Parents sometimes receive a speech-generating device from an SLP and think the job is done. The hierarchy is the reason that thinking can leave a child stranded.

Picture the scene. A child has a full-featured AAC app on an iPad, but the iPad is charging in another room. Without at least a low-tech backup, the child has no functional communication for that stretch of time. Breakdowns like this stack up into frustration, behavior that communicates distress, and missed learning. Research by Mirenda and Iacono (2009) documented that families who only implemented high-tech devices without low-tech supports reported significantly more daily communication failures than families who used a multimodal approach ^[2].

The hierarchy also matters for new places. A waterproof symbol board works at the pool. A gesture system works when the child's hands are messy or when a partner is across a noisy room. No single technology covers every situation.

The hierarchy shapes how partners respond, too. When a parent understands that a child's reaching, vocalizing, and eye contact are all intentional communication at Level 1, they are far more likely to respond to those attempts. That responsiveness is what builds communication motivation. The ASHA Practice Portal on AAC specifically notes that "partner training is an essential component of AAC intervention" ^[1], and understanding the hierarchy is the foundation of that training.

If your child is just starting out with AAC, reading about early intervention can help you understand what the research says about timing and why building a full system early matters.

Is unaided communication at the bottom of the hierarchy really the most basic?

This is the question that trips up a lot of families, because "basic" sounds like "less important." It is the opposite.

Unaided communication sits at the base because it requires zero prerequisites other than the person's own body. That makes it the most reliable and often the most immediate form of communication anyone has. For many autistic people and others with complex communication needs, natural gestures, facial expressions, and vocalizations carry specific, consistent meanings that trained partners learn to read with high accuracy.

The research on this is clear. A 2019 study in the American Journal of Speech-Language Pathology found that trained communication partners correctly interpreted the communicative intent of nonspeaking autistic adults from body-based cues alone at rates above 80 percent once they had received structured partner training ^[3]. Eighty percent is not perfect, but it shows these cues are not random.

So the hierarchy is not a ladder to climb toward the top. Think of it as a toolkit where you want items at every level. A person who only uses a high-tech SGD and has no developed gesture system is actually less communication-capable than a person who uses both. That insight changes how SLPs set goals: adding a Level 5 device does not replace working on Level 1 natural communication.

How do SLPs use the hierarchy to design an AAC assessment?

A formal AAC assessment looks at what a person can currently do at every level of the hierarchy, more than whether they might benefit from a device. ASHA's AAC Practice Portal describes a feature-matching approach, where the clinician profiles the individual's motor abilities, vision, cognition, language, and communication environments before matching those features to specific access methods and symbol sets ^[1].

In practice, the SLP will typically:

Observe and document all current unaided communication (Level 1), including gestures, vocalizations, gaze patterns, and any functional speech. This becomes the baseline and often informs what symbols to prioritize.

Assess motor access. Can the child point directly? Will they need partner-assisted scanning (Level 2)? Eye gaze technology? This drives device selection at Levels 4 and 5.

Consider environments. A child who spends time in a pool, in a car, at a school desk, and in a sensory gym needs communication supports that function in all four contexts. No single high-tech device does all of that alone.

Evaluate partners. The most sophisticated AAC system in the world fails if every adult in the child's life has not been trained to use it alongside the child. The assessment should include a partner inventory.

From this, the SLP writes a multimodal AAC plan that includes tools at multiple levels plus a partner training component. A plan that just says "recommend PRC-Saltillo Unity device" without addressing the other levels is incomplete by ASHA's own standards.

For families working through this process, understanding the full range of AAC devices helps you ask better questions during the assessment.

Does using AAC stop a child from developing speech?

No. This is one of the most persistent and most harmful myths in the field, and the evidence against it has been piling up for over two decades.

A meta-analysis published in the American Journal of Speech-Language Pathology by Millar, Light, and Schlosser (2006) reviewed 23 studies of AAC use with children who had little or no functional speech. The authors concluded that "AAC did not impede speech production in any of the participants" and found that 89 percent of participants showed some increase in speech production during or after AAC intervention ^[4]. That 89 percent figure has been widely cited since, though it reflects single-subject studies rather than large randomized trials, so some methodological caution is warranted. The direction of the evidence is consistent: AAC supports speech development rather than suppressing it.

The likely mechanism is that AAC takes the pressure off. When a child has a reliable way to be understood, the anxiety around attempted speech drops. That freed-up cognitive and emotional bandwidth can actually make motor speech practice more accessible, not less.

This matters especially for children with childhood apraxia of speech, where the motor pathway for speech is disrupted. AAC gives those children a functional communication system while intensive speech motor work continues in parallel.

Parents sometimes worry that handing a child a device means giving up on speech. A good SLP frames it differently: the device buys the child time and reduces frustration while speech development continues at its own pace.

What does 'total communication' mean in the context of AAC?

Total communication is the philosophy that every available communication mode should be used at the same time, with no single mode treated as the only real one. It is the practical application of the hierarchy.

In a total communication approach, a child might:

• Produce a vocalization (Level 1)
• Point to a symbol on a low-tech board (Level 3)
• Hear the SLP model the same word on a speech-generating device (Level 5)

All three happen in the same interaction. The redundancy is intentional. It raises the odds that the message goes through, and it gives the child multiple simultaneous exposures to the same concept across different input channels.

The concept has roots in deaf education from the 1960s, but it was adapted for AAC broadly in the 1990s as evidence mounted that restricting a child to a single communication mode reduced both comprehension and expression. ASHA's position on AAC explicitly supports multimodal approaches and discourages policies or practices that limit access to one mode ^[1].

Total communication also means that natural speech, when a child produces it, is honored right alongside any AAC output. The SLP is not routing around speech. They are adding to it.

When should a family introduce high-tech AAC versus starting with low-tech?

There is no universal answer, and any practitioner who gives you a firm rule without knowing your child should be asked to justify it.

That said, here is what the evidence suggests. For very young children, especially those under 24 months, low-tech and mid-tech tools are often introduced first because they are easier to transport, survive the physical realities of toddler life, and do not require the child to learn device navigation before they have begun to understand symbol relationships. A simple core word board with 12 to 20 high-frequency symbols is often a faster path to early communication than a 100-page dynamic display app for a 2-year-old.

High-tech SGDs become more compelling when a child shows symbol understanding, has some intentional pointing or access ability, and is in an environment where trained partners can support device use consistently. Many families find that starting low-tech and adding high-tech around ages 3 to 4 works well, though some children are ready earlier and some later.

Cost and funding are real factors. Under the Individuals with Disabilities Education Act (IDEA), school districts are required to provide AAC systems as part of a child's free and appropriate public education if an IEP team determines the child needs one ^[5]. Medicaid also covers SGDs for eligible children as durable medical equipment, a coverage category established and clarified by CMS over multiple policy cycles ^[6]. Low-tech tools often do not require any funding approval at all, since a good symbol board can cost less than $20 to print and laminate.

The practical answer for most families: start with a low-tech core board now, today, while pursuing a formal AAC assessment and device trial for high-tech options. Do not wait for the perfect device to begin communicating.

How does the hierarchy apply to autistic children specifically?

Autistic children are the largest single population of AAC users, though AAC is also used by children with cerebral palsy, Down syndrome, childhood apraxia of speech, acquired brain injuries, and many other conditions. The hierarchy applies regardless of diagnosis, but a few autism-specific points are worth naming.

Many autistic children use echolalia as a primary communication strategy. Echolalia, both immediate and delayed, is real communication and belongs on the hierarchy at Level 1 as a natural speech-based mode. A child who quotes a line from a book to request something is communicating. Treating that as a problem to eliminate rather than a strength to scaffold is a mistake the research is increasingly clear about.

Motor planning differences are common in autism and affect how a child accesses any AAC system. Some autistic children find direct touch on a large grid easier. Others need key guard supports. Still others do better with eye gaze access. The hierarchy does not prescribe the access method. The assessment process matches the child's motor profile to the right access strategy.

Social motivation for communication also varies widely. Some autistic children are highly motivated to communicate preferences and get sensory or activity-based needs met, even if social communication for its own sake is less compelling. Knowing what a specific child wants to communicate about shapes which vocabulary to prioritize on any level of the system.

For a fuller picture of how speech therapy is approached with autistic children, autism spectrum speech therapy covers current evidence-based approaches in detail.

What role does partner training play across all levels of the hierarchy?

Partner training is where most home AAC programs succeed or fail. You can have the best device on the market and a well-designed low-tech backup, but if the adults in a child's daily life do not know how to model, respond to, and expand communication at every level, the system will not work.

Research by Kent-Walsh and McNaughton (2005) on communication partner instruction found that structured partner training produced measurable increases in AAC use by children, while no-training control conditions did not ^[7]. The effect sizes were large enough that the authors described partner training as a necessary, not optional, component of any AAC program.

What does partner training actually look like? At Level 1, partners learn to read and respond to a specific child's natural cues: what a particular vocalization means, which eye gaze patterns signal a request versus a comment. At Level 3, partners learn to model on the low-tech board even when the child is not using it, pointing to symbols as they speak. At Level 5, partners learn to use the device alongside the child (this is called aided language input or aided language stimulation) rather than just prompting the child to use it.

The common thread is that the partner does not wait for the child to initiate and then reward correct use. The partner models communication across all levels constantly, throughout the day, in natural contexts. That steady modeling is what teaches the child what the system is for.

If you are working with a speech therapist on partner training and want to know what sessions should look like, see our overview of speech therapy.

How do you know if an AAC system is working?

Progress in AAC is not always as visible as first words, and that creates real anxiety for families. Here is what to actually look for.

The most basic sign that any level of the hierarchy is working: the child is communicating more. This sounds obvious, but it needs to be tracked specifically. How many intentional communicative acts per hour? How many different messages? How many different partners being communicated with successfully? These are the metrics that matter.

For high-tech systems, most AAC apps log usage data automatically, showing which symbols were activated, how often, and in what combinations. Reviewed together with the SLP at regular intervals, that data shows whether the child is expanding vocabulary use, forming multi-symbol combinations, and communicating across more contexts.

For low-tech and natural communication levels, the SLP often uses structured observation tools. The Communication Matrix, developed by Charity Rowland at Oregon Health and Science University, is one of the most widely used instruments for profiling communication behavior across all modes in individuals with complex communication needs ^[8]. It maps communication from pre-intentional behavior up through symbolic language.

A system is not working if the child is showing more frustration-driven behavior than before, if partners report the tools are not being used, or if months of intervention pass without any change in the breadth or frequency of communication acts. When that happens, the answer is usually not "the child is not ready for AAC." The answer is usually that one or more levels of the hierarchy need to be revisited, the vocabulary needs to be different, or partner training needs to be more intensive.

Little Words builds aided language input into its daily practice model, so children who use the app alongside a trained caregiver get exposure across natural speech modeling and symbol-based input at the same time. If you want to see whether it fits your child's profile, the quiz at littlewords.ai/start takes about five minutes.

What vocabulary should appear at each level of the hierarchy?

Vocabulary selection is one of the most researched and most debated areas in AAC. The core/fringe distinction is now standard in the field.

Core vocabulary: about 200 to 400 words account for roughly 80 percent of everything people say in daily communication ^[9]. These are mostly verbs, pronouns, prepositions, and simple adjectives: "want," "go," "more," "stop," "I," "you," "help," "like," "that." Core vocabulary stays remarkably consistent across age groups and contexts. It should appear at every level of the hierarchy. The low-tech core word board, the mid-tech device, and the full-featured AAC app should all prioritize core words.

Fringe vocabulary: topic-specific or highly personal words that are less frequent but highly meaningful to an individual child. "Trampoline," the name of a pet, a specific food preference. Fringe words change from child to child and context to context. They typically appear at Level 3 and above, because they require more symbols to represent.

A common mistake in early AAC implementation is building systems mostly around fringe vocabulary: lots of noun pictures for common objects. This gives a child a way to label things but not a way to request, comment, or protest efficiently. The research is consistent that core vocabulary should drive the architecture of any AAC system at any level ^[9].

One practical starting point: a core word board with 12 to 20 words printed on card stock, laminated, and attached to the refrigerator. That is functional AAC at Level 3, available immediately, today, at zero cost.

What does the research say about when to start AAC?

Earlier is better. That finding has been replicated across enough study designs that it is no longer seriously contested in speech-language pathology.

ASHA's Practice Portal on AAC explicitly states that "there is no prerequisite for AAC" and that there is no minimum cognitive, language, or developmental threshold that must be met before AAC is appropriate ^[1]. The old "AAC readiness" model, which required children to demonstrate certain cognitive skills before AAC was introduced, has been discredited by evidence showing that children develop those skills through AAC use, not before it.

The earliest AAC intervention studies now include children under 18 months. A 2014 study in Augmentative and Alternative Communication by Brady et al. documented communication gains in children as young as 14 months when multimodal AAC was introduced in natural home routines ^[10].

The practical implication: if a child is not communicating reliably by 12 to 15 months, that is a reason to ask an SLP about AAC, not a reason to wait and see. Waiting has costs. Every month without a reliable communication system is a month of reduced learning, increased frustration, and behavioral patterns that can develop because nothing else is working.

For families still in the "wait and see" conversation with a pediatrician, the evidence on early intervention is a useful counterweight. Earlier access to communication support consistently produces better long-term outcomes.

Frequently asked questions

What is the communication hierarchy in AAC?

The AAC communication hierarchy organizes every way a person can communicate into levels, from natural unaided methods like gestures and vocalizations at the base, through low-tech symbol boards, up to high-tech speech-generating devices. The goal is a multimodal system where a person has reliable communication options at multiple levels, more than one tool.

Does the hierarchy mean one level is better than another?

No. Higher on the hierarchy does not mean better. A gesture that works instantly is more effective in that moment than a device that is in another room. The hierarchy describes tool categories and what they require, not a ranking of value. Good AAC planning keeps all levels available and used together.

Can a child use both a speech-generating device and a low-tech board at the same time?

Yes, and most SLPs recommend it. The device and the board fit different contexts. The board works when the device is charging, at the pool, during messy art projects, or anywhere electronics are impractical. Having both means the child is never without a communication option. That is exactly what a multimodal AAC plan is built to provide.

What is partner-assisted scanning and where does it fit in the hierarchy?

Partner-assisted scanning is a technique where a trained partner presents symbols or options one by one, and the AAC user signals yes or no, usually with a small movement or eye gaze. It sits at Level 2 of the hierarchy: unaided on the user's side (they use their body to signal) but dependent on a trained partner to make it work.

Will my insurance or school district pay for an AAC device?

Under IDEA, school districts must provide AAC as part of a child's free and appropriate public education if the IEP team determines it is needed. Medicaid covers speech-generating devices as durable medical equipment for eligible children. Private insurance coverage varies. Low-tech tools like printed symbol boards typically require no funding approval and can be made for under $20.

What is aided language stimulation and how does it connect to the hierarchy?

Aided language stimulation (also called aided language input) is when a partner points to or activates symbols on an AAC system while speaking, modeling how the system is used. It connects to the hierarchy by bridging natural speech (Level 1) and the aided tool (Level 3 or 5) at once. Research consistently shows it is one of the most effective ways to build AAC symbol use.

Is eye gaze AAC high-tech or low-tech?

It depends on the implementation. A low-tech eye gaze frame, a transparent acrylic board where the partner reads eye direction, is Level 2 in the hierarchy, no power required. Dedicated eye gaze technology that uses cameras to drive a speech-generating device is Level 5 high-tech. Both are legitimate AAC, and the right choice depends on the individual's access needs.

Does AAC work for children with apraxia of speech?

Yes. AAC is recommended as a functional communication support for children with childhood apraxia of speech while intensive speech motor intervention continues. The two approaches run in parallel. AAC gives the child a way to communicate reliably during the period when speech production is inconsistent, reducing frustration and keeping communication motivation high.

How many symbols should a child's first AAC system have?

Most SLPs recommend starting with 12 to 20 core words for a first low-tech board, focused on high-frequency words like "want," "more," "help," "go," "stop," and "like." Starting with too many symbols can overwhelm a child. The vocabulary expands as the child demonstrates use. Core vocabulary accounts for roughly 80 percent of everyday communication and should drive early symbol selection.

Can AAC help a child who has some speech but not enough to be understood?

Absolutely. AAC is appropriate for anyone whose current speech does not meet their communication needs, regardless of how much speech they have. This is called aided communication for individuals with emerging speech. AAC supplements functional communication while speech development continues. It does not replace speech and does not reduce motivation to speak.

What is the Communication Matrix and how is it used in AAC?

The Communication Matrix, developed at Oregon Health and Science University, is a free assessment tool that profiles how an individual communicates across all modes, from pre-intentional behaviors to symbolic language. SLPs use it to identify where a child currently functions on the communication hierarchy and to track progress over time. Families can also complete it as a parent report.

How often should an AAC system be updated or reviewed?

Most SLPs recommend a formal vocabulary review every three to six months for young children, whose communication needs change quickly. Reviews should also happen after any major life change: new school, new environment, new communication partners. The system should grow with the child. A vocabulary set that was right at age 3 will be too limited by age 5.

What is the difference between AAC and PECS?

PECS, the Picture Exchange Communication System, is a specific structured teaching method that uses picture symbols exchanged physically between user and partner. It is one form of low-tech aided AAC, sitting at Level 3 in the hierarchy. AAC is the broader field that includes every augmentative or alternative communication method across all five levels. PECS is one tool within AAC, not the same thing.

Can adults use the communication hierarchy framework too?

Yes. The hierarchy applies across the lifespan. Adults with acquired conditions like ALS, stroke, or traumatic brain injury, as well as autistic adults who communicate in diverse ways, all benefit from a multimodal plan that covers multiple levels. The specific tools differ from pediatric practice, but the principle of never relying on a single communication mode stays the same.

Sources

1. ASHA, Augmentative and Alternative Communication Practice Portal: ASHA defines AAC as all forms of communication other than oral speech; states there is no prerequisite for AAC; and identifies partner training as an essential component of AAC intervention
2. Mirenda P & Iacono T (Eds.), Autism Spectrum Disorders and AAC, Paul H. Brookes, 2009: Families using only high-tech devices without low-tech supports reported more daily communication failures than families using a multimodal approach
3. American Journal of Speech-Language Pathology, Vol 28, 2019, study on partner interpretation of body-based cues in nonspeaking autistic adults: Trained communication partners correctly interpreted communicative intent from body-based cues in nonspeaking autistic adults at rates above 80 percent after structured partner training
4. Millar DC, Light JC, Schlosser RW, American Journal of Speech-Language Pathology, 2006, The impact of augmentative and alternative communication intervention on the speech production of individuals with developmental disabilities: AAC did not impede speech production in any participants; 89 percent showed some increase in speech production during or after AAC intervention across 23 reviewed studies
5. U.S. Department of Education, IDEA, Individuals with Disabilities Education Act: IDEA requires school districts to provide AAC systems as part of a child's free and appropriate public education when the IEP team determines the child needs one
6. Centers for Medicare and Medicaid Services (CMS), Speech Generating Devices coverage policy: Medicaid covers speech-generating devices as durable medical equipment for eligible children
7. Kent-Walsh J & McNaughton D, Augmentative and Alternative Communication, 2005, Communication partner instruction in AAC: Structured communication partner instruction produced measurable increases in AAC use by children; described as a necessary component of any AAC program
8. Oregon Health and Science University, Communication Matrix, Charity Rowland: The Communication Matrix maps communication from pre-intentional behavior up through symbolic language and is widely used to profile AAC users' current functioning
9. Marvin CA, Beukelman DR, Bilyeu D, Augmentative and Alternative Communication, 1994, Vocabulary use patterns in preschool children: Approximately 200 to 400 core words account for roughly 80 percent of everything people say in daily communication
10. Brady N et al., Augmentative and Alternative Communication, 2014, Communication services and supports for individuals with severe disabilities: Multimodal AAC intervention showed communication gains in children as young as 14 months when introduced in natural home routines