What the research says about visual supports (and what it doesn't)

A “visual support” is anything that shows a person information instead of only telling them: a photo of what’s happening next, a strip of pictures for the morning routine, two cards saying first this, then that, a shape on a screen that empties as the time runs down.

They are recommended constantly, and usually with more confidence than the research supports. This is what the evidence actually says — including the part that’s less comfortable, which is the part most likely to be missing from everything else you’ve read.

They are on the evidence-based list

The most thorough recent stocktake is a 2020 review from the National Clearinghouse on Autism Evidence and Practice at the University of North Carolina (Steinbrenner and colleagues). The team went through peer-reviewed research published between 1990 and 2017 and identified 28 practices that met their standard for being called evidence-based.

Visual supports is one of the 28. It was supported by 65 articles in their evidence base. Their definition is worth reading closely, because it says what these things are for:

“A visual display that supports the learner engaging in a desired behavior or skills independent of additional prompts.”

Note the last three words. The point of a visual support is that the person needs less help from us, not more.

Two honest limits on that review. It covered people from birth to age 22, so it says almost nothing about adults — even though visual supports are used with adults every day, in day programs, supported accommodation and workplaces, and often well. And the review’s own authors are clear that being on the list doesn’t mean everyone should use everything on it; the practice still has to suit the person.

On adults specifically, the closest thing to an answer is a 2025 review of digital activity schedules — the kind on a phone or tablet. Its 17 studies covered ages 3 to 45, including adults in vocational programs, and found positive effects across every age group. But only one of those 17 studies met the quality standard the reviewers applied, so read it as “this is being used with adults and appears to help” rather than as proof. The same review found something worth knowing if you work in someone’s home: of 17 studies, exactly one took place in one.

What they’re good at

A 2015 review by Knight, Sartini and Spriggs looked specifically at visual activity schedules — the picture-strip kind. They found 31 studies published between 1993 and 2013, of which 16 met their quality standard. Their conclusion was deliberately careful:

“Results suggest that VAS can be considered an EBP for individuals with ASD, especially when used in combination with systematic instructional procedures.”

Two things in that sentence do a lot of work.

“Can be considered” — this is a cautious verdict, not a proof.

“Especially when used in combination with systematic instructional procedures” — which is the academic way of saying someone has to teach it. A schedule that gets stuck on the fridge and pointed at is not the thing that was studied. In all but three of the studies they reviewed, the schedule came with teaching attached — going through it alongside the person and then gradually giving less help, with prompts and praise. The reviewers put it bluntly: in some of the studies the schedule on its own produced no change at all, and things only moved once it was properly taught.

The outcomes those studies went after are the practical ones. The reviewers list them as staying with a task, staying with the schedule, transitioning independently, starting a task sooner after being asked, completing more of the steps correctly — and needing fewer prompts from an adult to get through a transition.

That’s the well-supported claim: visual supports help people know what’s coming and do things more independently.

Three limits worth carrying with it, all of which the reviewers name themselves. Most of the research happened in primary schools, so home and community settings are thinner ground. Most of it looked at play and leisure activities rather than daily-living routines. And they specifically call for future studies to work out how much the schedule by itself contributes, separate from everything bundled with it — which is the thread the next section picks up.

Which pictures? The honest answer is “try it with them”

People ask whether to use objects, photos, symbols or words, and there’s a widely repeated ladder that supposedly answers it: real objects, then photographs, then drawings, then written words, climbed in order.

The ladder traces back to a 1989 study (Mirenda and Locke) that showed forty people who did not use speech eleven kinds of picture and asked them to identify what each one meant. Real objects were recognised most readily; Blissymbols and written words were hardest.

That’s a real finding about one group of people. It was never a ladder, and three later lines of research explain why it can’t be used as one.

Being easy to recognise isn’t the same as being easy to learn. In 2018, Sevcik and colleagues taught thirteen school-age children with developmental and language delays both picture-like symbols and completely arbitrary ones. The difference was modest — and it disappeared entirely when the child didn’t already know the word the symbol stood for. An earlier study teaching four autistic children to request found much the same: how picture-like the symbol was made little difference to how quickly they learned it. What matters more is whether they know the thing yet.

“Symbols” is not one thing. A 2024 study rated 1,525 pictograms from a single widely used symbol set for how guessable they are. The average was low, and the spread was enormous — from completely obvious to completely opaque within the same set. More than half the pictograms were given a name other than their official label by the people looking at them. Symbols for objects scored roughly twice as well as symbols for actions.

That last point is worth sitting with, because a schedule is mostly actions. “Toothbrush” is an easy picture. “Get dressed” is not. So the question isn’t “do symbols work for this person” — it’s “does this symbol work for this person”, and expect the doing-words to be the hard ones.

Individual variation swamps the average. A 2025 study taught six young autistic children to use either picture symbols or plain written text. Two learned both. Four struggled with both — and the researchers’ conclusion was that those four probably needed something else entirely: photographs, a different layout, a different way of being taught. Current professional guidance on communication symbols reflects this. It sets out no concrete-to-abstract progression at all; it matches the type of symbol to the individual.

So what do you actually do?

The clearest practical rule comes from a free US Department of Education practice guide on visual activity schedules:

“A student should be able to understand what each step of the VAS represents with little to no guidance… If the student is working on reading new words or understanding different modes of images, these should not be included in the VAS.”

In other words: a schedule is not the place to teach a new kind of picture. Use what they already understand without help. If they’re still learning to read words, the schedule shouldn’t be words yet.

Which makes it a two-minute practical question, not a theoretical one. Hold out two real objects and ask for one. Show a photo of their cup and a photo of their shoes and ask which is the cup. Do the same with two symbols. Use whatever they get right without being helped, and if you’re unsure, go one step more concrete than you think they need — it costs nothing to move up later.

And the properly honest note: that same practice guide points out that the published studies often don’t say how they chose the type of picture in the first place. There is no formula in the research. There’s your own two-minute test, and the willingness to change it if it isn’t working.

The part that gets left out

Here is the finding that changes how these tools should be described.

In 2009, Waters, Lerman and Hovanetz worked with two six-year-old boys whose transitions from a preferred activity to a non-preferred one were going badly — hitting, kicking, throwing things. Both boys had already been taught to use picture schedules at school.

They added the visual schedule. The difficult behaviour didn’t change. It kept happening in essentially every transition.

What did change things was altering what happened afterwards. Previously, the behaviour worked: the transition got called off and the preferred activity came back. When that stopped being true, and the boys got praise and something they liked for getting through a transition without it, the behaviour dropped sharply — by 61% and 77%. With the visual schedule also in place, it dropped a bit further, by 76% and 89%.

On its own that study proves very little — two children, a short evaluation, and later methodological reviews rated it weak. But it has since been repeated, with more people and for longer.

In 2023, Tanya Mouzakes ran the same comparison in a school, with three students aged 9, 14 and 17. All three already used visual supports in their classrooms every day. The schedules were tried with and without the change to what happened afterwards, across two studies, including transitions deliberately made harder to predict. The result was the same for all three: the schedule made no difference to the difficult behaviour, to how long the transition took, or to whether they moved off on their own.

Then she asked them. Given the choice, two of the three students chose to do their transitions without the schedule, and every staff member chose to work without it too.

Why it didn’t help — which is the useful part

That sounds damning until you look at why, and the why is the most practical thing in this whole article.

Before any of it, each student had a proper look at what was actually driving the behaviour. For two of them it turned out to be the physical move itself — getting up and walking somewhere. For the third it was losing the good activity and being handed a boring one. For none of them was the problem not knowing what was coming.

So the schedule was aimed at a difficulty they didn’t have. A picture of the next room doesn’t help someone who already knows exactly which room it is and would rather not go.

A 2014 practice guide (Brewer and colleagues) had set out these conditions in advance, and they hold up well:

Telling them what’s coming is unlikely to help when…	It is likely to help when…
The trouble is losing a good activity, or being made to start a boring one — rather than not knowing what’s happening	The person genuinely can’t predict when the change is coming, or what’s on the other side of it
Getting upset has reliably brought the good thing back, or called the transition off	Getting upset doesn’t cancel the transition
The move is from something great to something much worse	The warning is given in a form that person actually understands

The right-hand column is the one worth pinning up. It’s also, roughly, a description of a new routine, an unfamiliar place, an appointment, a first day, a changed plan — and those are situations where visual supports have a lot to offer.

Read down the columns rather than across: these are two sets of conditions, not three matched pairs.

One more piece of context. A 2025 review by Mouzakes and Thompson went looking for studies designed carefully enough to isolate what the schedule itself contributes, and found only seven — of which just one measured difficult behaviour during transitions. So the honest position isn’t that schedules have been tested and failed. It’s that they’re nearly always bundled with other things that work, and almost nobody has separated them out.

So what does that add up to?

Not “visual supports don’t work.” That would be a much bigger claim than any of this supports, and in the Waters study the combination did slightly better than the change on its own — the authors themselves suggested schedules “might enhance” it.

What it adds up to is a targeting question. Two different jobs:

The job	Is a visual support the right tool?
Knowing what’s happening and what’s next	Yes — this is what the evidence supports
Following a routine with less help	Yes — independence is the best-evidenced outcome
Making an unfamiliar or unpredictable situation less unknown	Yes — this is the condition under which advance notice works
Changing what someone does when a good thing ends	Not on its own. This is different work

If a transition is still going badly even though the person knows exactly what’s coming, the missing piece isn’t more information. It’s whatever is keeping the behaviour going — and working that out is what a behaviour support practitioner does. Worth noticing that in every study above, the useful move was made after somebody had established what was actually driving it. The schedules that failed weren’t badly made. They were pointed at the wrong thing.

The hopeful version

This is not a discouraging body of evidence. It’s a specific one.

Showing someone what’s coming is cheap, it’s quick, it carries essentially no risk when it’s done sensibly, it’s one of the least intrusive things anyone can try, and for a lot of people it makes real days genuinely easier. That’s a good deal. It’s just not the same as a treatment, and describing it as one sets people up to feel like they failed at something that was never going to do that job by itself — the parent who laminated it, the worker who kept it going across a roster, the teacher who built it into the day.

The visual timer and First/Then board on this site are built to sit exactly inside what the evidence supports, and no further. There’s a practical guide to using them well, and a plainer piece on why transitions are hard in the first place.

If the hard part is what happens when something good has to end, that’s worth a conversation — get in touch.

Sources

• Steinbrenner, J. R., Hume, K., Odom, S. L., et al. (2020). Evidence-Based Practices for Children, Youth, and Young Adults with Autism. University of North Carolina at Chapel Hill, Frank Porter Graham Child Development Institute, National Clearinghouse on Autism Evidence and Practice Review Team. Full report, free via ERIC
• Knight, V., Sartini, E., & Spriggs, A. D. (2015). Evaluating visual activity schedules as evidence-based practice for individuals with autism spectrum disorders. Journal of Autism and Developmental Disorders, 45(1), 157–178. doi:10.1007/s10803-014-2201-z
• Hugh, M. L., Conner, C., & Stewart, J. (2018). Intensive Intervention Practice Guide: Using Visual Activity Schedules to Intensify Academic Interventions for Young Children With Autism Spectrum Disorder. Washington, DC: US Department of Education, Office of Special Education Programs. Free full text
• Mirenda, P., & Locke, P. A. (1989). A comparison of symbol transparency in nonspeaking persons with intellectual disabilities. Journal of Speech and Hearing Disorders, 54(2), 131–140. doi:10.1044/jshd.5402.131
• Sevcik, R. A., Barton-Hulsey, A., & Romski, M. (2018). Visual-graphic symbol acquisition in school age children with developmental and language delays. Augmentative and Alternative Communication, 34(4), 265–275. PubMed
• Angermeier, K., Schlosser, R. W., Luiselli, J. K., Harrington, C., & Carter, B. (2008). Effects of iconicity on requesting with the Picture Exchange Communication System in children with autism spectrum disorder. Research in Autism Spectrum Disorders, 2(3), 430–446. ERIC record
• Díez, E., Díez-Álamo, A. M., Alonso, M. A., Wojcik, D. Z., & Fernandez, A. (2024). Transparency and translucency indices for 1,525 pictograms from the Aragonese Portal of Augmentative and Alternative Communication. Frontiers in Psychology, 15, 1467796. Free full text
• Pope, L., & Light, J. (2025). Comparison of learning text vs. picture symbol AAC representations for young children on the autism spectrum. Augmentative and Alternative Communication. PubMed
• American Speech-Language-Hearing Association. Augmentative and Alternative Communication (Practice Portal). asha.org
• Mouzakes, T. N. (2023). Identifying the active components of a visual schedule intervention in a school setting. Doctoral dissertation, Western New England University. Free full text
• Waters, M. B., Lerman, D. C., & Hovanetz, A. N. (2009). Separate and combined effects of visual schedules and extinction plus differential reinforcement on problem behavior occasioned by transitions. Journal of Applied Behavior Analysis, 42(2), 309–313. Free full text
• Brewer, A. T., Strickland-Cohen, K., Dotson, W., & Williams, D. C. (2014). Advance notice for transition-related problem behavior: practice guidelines. Behavior Analysis in Practice, 7(2), 117–125. Free full text
• Mouzakes, T. N., & Thompson, R. H. (2025). A closer examination of the visual schedule component of interventions to improve transitions. Behavioral Interventions. doi:10.1002/bin.70028