Beyond words: The role of alternative communication in hearing the voice of the child in paediatrics

Background:
The right of children to express their views in all matters affecting them is enshrined in Article 12 of the UN Convention on the Rights of the Child (1989). However, the ‘voice of the child’ extends beyond spoken language. Clinical discussions often rely on verbal communication, leaving pre-verbal, non-speaking, non-English-speaking, and silenced children disadvantaged. This project sought to address these inequities by exploring the practical use of alternative communication methods in paediatrics and piloting a multi-site visual communication toolkit designed specifically for child protection contexts.

Methods:
A systematic literature review was undertaken using Ovid Medline and Embase to identify studies evaluating visual and alternative communication strategies with children. In parallel, a visual communication toolkit—My Voice Matters—was co-designed with 126 London schools and safeguarding teams from 26 NHS trusts. The toolkit drew on speech and language therapy approaches and aimed to promote accessible, child-centered participation.   Toolkits were placed in all community clinic rooms and used during all child protection medical assessments in four London boroughs.  Communication stations containing additional alternative communication aids tailored to clinical conversations were introduced in a central London children’s hospital emergency department, a general paediatric ward, and two community child-health centers.

Results
Although more than 20,000 studies describe the benefits of alternative communication for children, translation into paediatric clinical practice remains limited. Only four studies were identified that evaluated its impact within clinical conversations. These studies demonstrate that communication tools empower children to share their own experiences and also enhance their understanding of clinicians’ perspectives.

Adapted from established speech and language therapy principles, My Voice Matters provides a clinically relevant, child-friendly toolkit designed to support meaningful participation in safeguarding discussions. During the first three months of implementation, the toolkit enabled eight children to disclose previously unreported experiences of abuse and almost doubled the proportion of cases in which the child’s voice was explicitly documented.

In the hospital setting, introducing communication stations across all clinical areas reduced the proportion of children reporting that they had not been heard from 9% to 0%. Concurrently, staff use of alternative communication methods increased from 17% to 96%, reflecting a significant shift towards more inclusive and child-centred communication practices.

Conclusions
Communication in paediatrics must extend beyond words. Children have both the right and the capability to participate in decisions about their care, but many lack accessible means to do so. Child-centred communication tools can make this right a practical reality—improving safety, equity, and care quality. Integrating communication toolkits such as My Voice Matters into everyday practice demonstrates how clinicians can uphold children’s rights, strengthen safeguarding and ensure that every child—regardless of language or ability—can truly be heard. Communication support should be universally available in all paediatric settings as a new standard of care.

Dr Claire Stewart is a paediatric registrar at the Evelina London Children’s Hospital and is the National Trainee Representative for the British Association of Community Child Health (BACCH).  She has won multiple national and international awards for leading transformative quality improvement initiatives that have changed standards. She has 16 peer reviewed publications and has spoken in over 40 national and international conferences.  Recognising that difficult subject matter can create a communication need in any child, her latest work to change the way the voice of the child is heard in clinical conversations and safeguarding proceedings to ensure a need for verbal communication is never a barrier to being heard is driving improvements in care and safeguarding practices across the UK.