Augmentative and alternative communication in autism: picture cards, devices and signs

Picture cards and visual symbols for children

For toddlers and preschool children, according to the guideline language support should first use comprehensive, low-frequency psychosocial therapies that in a natural learning format practise, for example, self-initiative, non-verbal communication (bringing, interpreting, showing) and joint attention. The parents should be intensively involved and guided in this. ^{[1, Rec. 31]} Children who have difficulty with this and make insufficient language progress can additionally be supported with picture cards or visual symbols combined with spoken sounds (also computer-based or with speech-output devices). This must be practised often and under direct guidance with different interaction partners. The picture cards serve as support and should be reduced as soon as the child begins to communicate with sounds and words. ^{[1, Rec. 31]} This is a weak recommendation (grade of recommendation C): it says it is possible, not that it is always necessary. For children in early primary school age, the methods can continue to be used; if picture cards are used, attempts should continue at the same time to encourage verbal expressions. ^{[1, Rec. 31]}

Non-speaking adolescents and adults

For non-speaking children from late primary school age, adolescents and adults, the guideline stated that the body of studies is not sufficient for an evidence-based recommendation; there is a consensus-based recommendation. ^{[1, Rec. 31]} According to it, a picture card system or a device that outputs speech via visual symbols can be used if no speaking develops after other methods have been used for long enough. The following should be noted: ^{[1, Rec. 32]}

• The devices must match the cognitive level of development and must not overwhelm through their complexity.
• The person must be systematically guided in communicative use; spontaneous expression should be in the foreground.
• It should be checked regularly whether the person selects the symbols appropriately.
• All interaction partners (for example teachers, parents, siblings) should respond in the same way to picture cards and devices so that the person experiences consistent success.

Signs

For children who neither acquire verbal language nor learn to communicate with picture cards, according to the guideline the use of individual signs can make sense in order to enable at least basic participation. The general introduction of a systematised sign language such as German Sign Language, by contrast, the guideline described as not very promising; it would rather limit the possibilities for participation. ^{[1, Rec. 32]}

What the guideline did not recommend

• Facilitated communication. So-called “facilitated communication” should, according to the guideline, not be used to promote language development or communication in people with autism, since there is no evidence for it (consensus-based, consensus). ^{[1, Rec. 35]}
• Auditory integration training and neurofeedback should not be used to treat language and speech disorders (grade of recommendation A). Medication should currently not be used for this (grade of recommendation B). ^{[1, Rec. 33]}

What else you should know

• Augmentative communication does not have to “replace” speaking. The guideline described picture cards as support that is reduced when spoken language begins. ^{[1, Rec. 31]}
• Everyone pulls in the same direction. Consistent reactions from all caregivers are important, according to the guideline. ^{[1, Rec. 32]}
• Aids and cost coverage are not covered in this article. Questions on them are clarified by advice: Finding advice.
• Dubious offers you recognise here: Recognising dubious offers.

Sources and literature

1. DGKJP, DGPPN et al. Autismus-Spektrum-Störungen im Kindes-, Jugend- und Erwachsenenalter. Teil 2: Therapie. S3-Leitlinie, AWMF-Reg.-Nr. 028-047, Stand Text 02.05.2021 (Empf. 31, 32, 33, 35). – Guideline (in German); expired on 23 March 2026 (see no. 2)
2. DGKJP. Aktuelle Leitlinien (Eintrag 028-047: „Gültig bis 23.03.2026“). https://www.dgkjp.de/wissen/aktuelle-leitlinien/ – Professional society (website in German)