This chapter examines Germany’s evolving approach to supporting individuals with ASD, highlighting a shift from limited recognition to a comprehensive rights-based framework. Over the past two decades, Germany has strengthened its legal foundations through the Social Code, the Disability Equality Act, and reforms under the Federal Participation Act, aligning national policy with the United Nations Convention on the Rights of Persons with Disabilities. While ASD prevalence data remain restricted to documented diagnosis in inpatient and outpatient care, Germany has introduced rigorous clinical guidelines for ASD diagnosis and therapy, widely respected by professionals. The chapter explores two key benefits: the Care Allowance, based on assessed care needs via long-term care insurance, and Integration Assistance, which provides tailored services or personal budgets to promote social participation and educational inclusion. It also reviews statutory health insurance coverage for therapies and the gradual, yet modest, progress toward inclusive education.
Policy Responses to Rising Autism Diagnoses in Childhood
Abstract
Autism policy in Germany: Legal framework and available supports
Initially, Germany was slow to recognise the rights and needs of people with ASD. However, in the last two decades Germany developed a strong legal basis for the protection of rights of people with disability, which includes individuals with autism.
Germany has no available data on the population prevalence of autism or rates of diagnosis, although data on documented autism diagnoses in inpatient and outpatient care indicate a considerable increase.
Germany has rigorous guidelines for the diagnosis and therapy for children, adolescents and adults with ASD. Although the guidelines are not compulsory, they are generally respected by professionals and considered as good practice in the medical community.
To access Germany’s Care Allowance administered by statutory long-term care insurance, a child with ASD must undergo an assessment of care needs conducted by an independent medical service. The assessment evaluates the child’s day-to-day support needs, determines whether these needs entitle the care provider to the allowance, and if so, assigns the child to one of five care‑need levels. Although medical documentation is required, a formal medical diagnosis, such as of ASD, is neither mandatory for eligibility nor sufficient on its own to qualify for a Care Allowance.
The number of children assessed for Care Allowance has risen considerably over the past decade, to about 162 000 assessments in 2024. This growth is likely linked to a far-reaching reform in 2017 expanding access for individuals with psychological or psychiatric conditions, including children with ASD, who had previously been disadvantaged in the assessment criteria.
Children with an ICD‑10 diagnosis F84 (pervasive developmental disorders, see Chapter 2) account for a substantial proportion of all children eligible for Care Allowance – around 15%. The largest single diagnostic group are children with a F90 (ADHD) diagnosis, representing roughly 21% of children receiving a Care Allowance.
Uptake of Integration Assistance, Germany’s other major financial support for children with disability – provided either as in-kind service or through a personal budget – has also increased in recent years. While the number of children with mental health conditions receiving the benefit continues to rise, growth among children with physical and/or intellectual disability appears to have slowed. Typically, children with ASD qualify for Integration Assistance under Social Code VIII (for mental disability), unless they also present intellectual and/or physical disabilities, in which case Social Code IX applies.
Germany’s statutory health insurance system covers medically prescribed rehabilitation services for children with disability, such as occupational and speech therapy. The Integration Assistance plays a more prominent role in financing supports aimed at social participation and educational inclusion – for instance, an integration aide at school for children attending regular schools who require additional support.
Despite a gradual shift toward inclusive education over recent years, most of Germany’s nearly 600 000 students with SEN in 2023/24 remain enrolled in special education schools.
Germany’s approach to supporting individuals with ASD has undergone significant transformation over the past two decades. Historically, recognition of the rights and needs of people with autism was limited, leaving families to advocate for services through legal channels. Today, Germany has established a robust legal framework aligned with international standards, notably through the ratification of the United Nations Convention on the Rights of Persons with Disabilities in 2009 and reforms under the Federal Participation Act (Bundesteilhabegesetz). While comprehensive population prevalence data on ASD remain unavailable, Germany has implemented rigorous clinical guidelines for diagnosis and therapy, widely respected within the medical community.
Beyond healthcare, Germany offers a multi-layered system of financial and social support designed to address the diverse needs of children with disability, including those with ASD. Two key benefits – Care Allowance and Integration Assistance – play complementary roles: Care Allowance compensates family caregivers based on assessed care needs, while Integration Assistance provides tailored services or a personal budget to promote social participation and educational inclusion. These measures are supported by statutory health insurance, which covers medically prescribed therapies such as occupational and speech therapy, ensuring that core rehabilitation services are accessible without direct cost to families. Education policy has also seen gradual progress towards inclusion, with increasing numbers of students with special educational needs (SEN) attending regular schools, although special schools continue to enrol most students with SEN, reflecting the ongoing challenge of implementing inclusive education nationwide.
Historically, people with autism in Germany often lacked recognition and support. Autism Germany, now the German federal Association for Autism (Bundesverband autismus Deutschland e.V.), was founded in 1970 by parents of children with ASD, to provide support for people with autism and their families. In parallel, the first autism therapy centres were established, an important step at a time in Germany when parents had to go to court to get therapy financed for their children, as service providers disputed the need for special autism therapies (Frese, 2017[1]).
Germany has developed a strong legal basis for the protection of rights of people with disability
In the past two decades, Germany’s disability rights framework has progressively evolved, strengthening considerably the rights of people with disability, including children with ASD. Legal provisions include (Frese, 2017[1]; Bundestag, 2021[2]):
Social Code (Sozialgesetzbuch, SGB) IX, which came into force in July 2001 and contains general provisions on the rehabilitation and participation of persons with disability in society. According to Section 2 of the Social Code, a person with disability is a person who has “physical, mental, intellectual or sensory impairments which, in interaction with attitudinal and environmental barriers, are likely to hinder their equal participation in society for more than six months. An impairment as defined in the Social Code exists if the physical condition and state of health deviate from the condition typical for the age” (Bundestag, 2016[3]). Additionally, regulations on “long-term care insurance” (an independent branch of the social insurance system) were introduced under the Social Code (SGB) XI in 1995 and apply to everyone with statutory or private health insurance.
The Disability Equality Act (Behindertengleichstellungsgesetz, BGG) came into effect in May 2002, laying down the equal treatment of people with disability in all areas of life and accessibility in the public sphere.
The General Equal Treatment Act (Allgemeine Gleichbehandlungsgesetz, AGG) came into force in August 2006, regulating the equal treatment of people with disability in civil law.
In March 2009, Germany ratified the United Nations Convention on the Rights of Persons with Disabilities which lays down important principles such as inclusive education and anti-discrimination. To implement the UNCRPD, Germany has passed comprehensive reforms of the Social Code, implemented through the Federal Participation Act (Bundesteilhabegesetz, BTHG), which has come into effect in stages between 2017 and 2023. The Social Code promotes self-determination, independent living and community inclusion. Notably, the Act updated SGB IX and SGB XII on social assistance to improve access to Integration Assistance and other services for people with disability, including people with autism.
In Germany, in contrast to other OECD countries, no data on the population prevalence of ASD is available to date. Administrative information and frequencies of autism diagnoses and cases are available using routine data from outpatient and inpatient care.
Analysis of outpatient claims data from a statutory health insurance fund (Handelskrankenkasse) for 2023 indicates that the proportion of children, adolescents, and young adults (aged 0‑24 years) with an outpatient ASD diagnosis increased from 0.4% in 2013 to 0.8% in 2019. Subsequently, this proportion remained largely unchanged until 2022. The most frequently documented outpatient diagnoses among these cases were F84.0 childhood autism (36.8%) and F84.5 Asperger syndrome (31.9%), based on the ICD‑10 classification system (Nymbach, 2023[4]).
Analyses of outpatient mental disorder diagnostic spectrum were conducted by the Central Research Institute of Ambulatory Healthcare in Germany on behalf of the Robert Koch Institute. These analyses revealed that both the absolute number and the proportion of ASD diagnoses among all outpatient mental disorder diagnoses increased between 2012 and 2024. The number and proportion of documented F84.0 childhood autism diagnoses rose from 0.56% (n=61 723) to 1.41% (n=252 414), the number of F84.1 atypical autism diagnoses from 0.11% (n=12 342) to 0.25% (n=44 183), and the number of F84.5 Asperger syndrome diagnoses from 0.28% (n=30 906) to 0.48% (n= 85 919) (Thom et al., 2024[5]).
The same trend was observed among adults. Between 2012 and 2024, the number and proportion of documented F84.0 childhood autism diagnoses increased from 0.06% (n= 61 559) to 0.13% (n=207 697), the number of F84.1 atypical autism diagnoses from 0.01% (n= 14 833) to 0.04% (n=59 947), and the number of F84.5 Asperger syndrome diagnoses from 0.02% (n=23 315) to 0.10% (n= 162 066) (Thom et al., 2024[5]).
Additional information is available from the Federal Statistical Office on the main diagnoses of patients during hospital stays. While autism rarely requires inpatient treatment – making these data unsuitable for estimating autism prevalence or for international comparisons – they do provide information on the frequency of diagnoses in inpatient care. Between 2000 and 2023, these frequencies increased substantially. The number of cases for pervasive developmental disorders (F84) rose almost threefold, from 1 283 in 2000 to 3 842 in 2023 (Statistisches Bundesamt, 2026[6]).
Germany has so-called S3 guidelines for a wide range of diseases and medical conditions that outline diagnostics and therapeutic treatment for the healthcare system. S3 guidelines are the most rigorous type of guideline issued by the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF) and they combine evidence‑based systematic analysis with a structured consensus-based process by an expert steering committee – thereby combining the requirements for an S1 guideline, which is based on recommendations by experts, and an S2 guideline, which is based on a structured consensus process or a systematic literature review.
The latest guidelines for autism spectrum disorders in childhood, adolescence and adulthood were issued in two parts: diagnostics and therapy. Part 1 on diagnostics was issued in 2016 and is currently being revised. Part 2 on therapy was published in 2021 and is valid until 2026 (AWMF, 2016[7]; AWMF, 2021[8]). According to these guidelines, Germany still uses and accepts older classifications for autism, as understood under DSM-III-R, DSM-IV-TR (Autism, Asperger’s disorder, PDD-NOS), and ICD‑10 (F84.0 Early Childhood Autism, F84.5 Asperger Syndrome, F84.1 Atypical Autism), in addition to the newer DSM‑5 classification of ASD (ibid.). As the healthcare system still uses ICD‑10 coding, diagnoses are often made, or at least recorded, according to ICD‑10 criteria, i.e. autism is still often referred to as pervasive developmental disorder rather than autism spectrum disorder.
Best practices for the diagnostic process in Germany
In Germany, most people receive their autism diagnosis from the public health system, but both in the public and in the private sector professionals generally follow the above‑mentioned S3 guidelines, which are considered industry standard. Part 1 of the S3 guidelines breaks down the diagnostic process into three steps: screening, referral and the diagnostic procedure itself (AWMF, 2016[7]).
Screening
Screening is generally done by the primary healthcare provider, if a child has pre‑defined risk factors and at least one additional symptom indicating autism. Pre‑defined risk factors include (ibid.):
Genetic findings with increased rate of ASD;
Drug exposure during pregnancy;
Viral infection during pregnancy;
Birth weight under 1500g;
Premature birth;
Neonatal seizures;
Siblings with ASD
Screening tools are optional, but if used, the guidelines recommend screening tools depending on the age and ability of the child. These are the following (ibid.):
for toddlers: Modified Checklist for Autism in Toddlers (M-CHAT);
for preschool and elementary school-aged children: Social Communication Questionnaire (SCQ);
for primary school aged children and adolescents with lower support needs: Marburg Assessment Scale for Asperger’s Syndrome (MBAS);
for children and adolescents with intelligence impairment: Scale for the Assessment of Autism Spectrum Disorders in the Less Abled (SEAS-M).
Referral
According to the S3 guidelines, referral should be made to a centre specialising in ASD diagnostics, if ASD seems clinically likely and/or if parents/caregivers also report corresponding symptoms (ibid.).
Diagnostic procedure
The diagnostic procedure is the main part of the assessment, at the end of which one or more professionals may establish an autism diagnosis. The assessment includes a variety of components, requiring a wide range of information to be gathered. According to the S3 guidelines, the assessment should be conducted by one or more healthcare professionals knowledgeable and skilled in mental and developmental disorders and in the use and interpretation of the appropriate screening instruments. The guidelines also describe the skills required by a professional participating in the diagnostic procedure, including skills in differential diagnosis, in performing internal medicine‑neurology examinations, and in professional counselling, among others. The guidelines also require that the diagnosis is made in consultation with one of the following (AWMF, 2016[7]):
a specialist in child and adolescent psychiatry and psychotherapy, or
a specialist in child and adolescent medicine who is specially qualified for this purpose.
The diagnostic process should include a detailed medical history and several medical examinations, such as an assessment of hearing and visual disturbances and a complete internal neurological examination. Autism-specific diagnostic testing should be performed, including a standardised interview with a parent or guardian, with the use of Autism Diagnostic Interview – Revised, ADI-R, recommended for children, and semi-standardised behavioural observation, with CARS (Childhood Autism Rating Scale) and ADOS‑2 (Autism Diagnostic Observation Schedule, Second edition) as the recommended tools. The guidelines highlight that standardised diagnostic instruments should be used in addition to clinicians’ observations and not replace a full autism assessment. Throughout the assessment process, differential diagnosis should also be considered and the child’s strengths, skills, level of impairments and needs should also be evaluated (AWMF, 2016[7]).
Germany provides two financial benefits for children with disability, both of which are available to families of children with ASD: Care Allowance (Pflegegeld) and Integration Assistance (Eingliederungshilfe), with the latter functioning as an additional cost allowance. Very few individual federal states offer supplementary benefits, as is the case in Bavaria where individuals with a care need level of 2 or higher are entitled to an additional annual payment of EUR 1 000 (Bayerisches Landesamt für Pflege, n.d.[9]).
Care Allowance provides cash support for home‑based care
Entitlement to Care Allowance, which is available to individuals with support needs of all ages, is primarily determined by the assessed level of care needs and designed to compensate those providing such care, in most cases family members. It is a monthly, non-means-tested benefit administered through the long-term care fund (Pflegekasse). Care Allowance is structured according to five levels of care need (the degree of care, or Pflegegrad), corresponding to the following monthly amounts in 2025 (Bundesministerium für Gesundheit, 2025[10]):
Level 1: EUR 0
Level 2: EUR 347 (approximately 8.3% of the average monthly wage in Germany in 2024)
Level 3: EUR 599 (approximately 14.3%)
Level 4: EUR 800 (approximately 19.1%)
Level 5: EUR 990 (approximately 23.6%)
In addition, a supplementary Relief Amount (Entlastungsbetrag) of up to EUR 131 per month is available at all care levels (1‑5). This amount is offered to reimburse quality-checked provisions to ease the workload of informal carers and to promote the independence and self-determination of people with care needs in the organisation of their everyday life (Pflege, 2025[11]). While individuals assessed at Level 1 (Pflegegrad 1) are not entitled to a Care Allowance, they are eligible for a range of other supports, including the Relief Amount, individual care counselling provided by their long-term care insurance, subsidies for aids and home adaptations, and free care training courses for relatives (Bundesministerium für Gesundheit, 2025[12]).
An assessment of the need for care is central to accessing the Care Allowance
While some form of medical documentation regarding the child’s or adult’s condition is required to qualify for Care Allowance, a formal medical diagnosis is neither mandatory nor sufficient on its own to guarantee eligibility. The primary determinant of entitlement is the individual’s assessed need for care and support. The Medical Service (Medizinischer Dienst) is commissioned by the person’s long-term care insurance and typically conducts these assessments in-person through a home visit or, if permitted by legal requirements, a telephone interview. Medical services are staffed by specially trained care professionals and physicians. The assessment is generally carried out by a single representative of the Medical Service, who consults directly with the person receiving care and/or their primary caregiver (Medizinischer Dienst, 2025[13]).
The assessment of care needs follows a standardised protocol that evaluates the child’s independence and required level of support across six key domains of daily life. Each domain is weighted differently in the overall evaluation of care needs: 1) mobility (10%); 2) cognitive and communicative abilities (15%); 3) behaviour and psychological issues (15%); 4) self-care (40%); 5) managing illnesses and therapies (20%); and 6) social participation and daily life structuring (15%). For each domain, the Medical Service assesses the extent of care and support a child requires compared to a child of the same age without a disability or long-term health condition. The assessor assigns scores for each domain, where higher scores indicate greater care needs. The weighted sum of these scores determines the child’s overall care level (Pflegegrad), which in turn defines the corresponding monthly allowance amount. The five care levels are divided as follows (Pflegeverband, 2025[14]):
Level 1: 12.5 to under 27 points
Level 2: 27 to under 47.5 points
Level 3: 47.5 to under 70 points
Level 4: 70 to under 90 points
Level 5: 90 to 100 points
In addition to determining the level of care need, the Medical Service may also suggest, where appropriate, assistive devices, preventive measures, medical rehabilitation, or adaptations to the home environment to help sustain a person’s independence or improve caregiving conditions. Reassessments of children’s care needs are typically carried out every two years, although the precise frequency may vary depending on individual circumstances. Reassessments can also be initiated at any time if the condition of the person receiving care changes; for example, the person concerned or their caregiver may request a reassessment when care needs are believed to have increased (Dr. Weigl & Partner, 2025[15]).
A major reform of Germany’s long-term care system – the “Care Strengthening Acts” of 2015‑2017 – fundamentally changed both the terminology and the methodology of care assessments. The reform introduced a more holistic approach evaluating physical, cognitive, and psychological or psychiatric impairments equally and comprehensively. As a result, individuals with psychological or psychiatric conditions, previously highly disadvantaged in the assessment process, have since gained improved access to the Care Allowance (Medizinischer Dienst Bund, 2025[16]).
The total number of Care Allowance recipients has been growing steadily
Since the major reform of Germany’s care system in 2017, the number of care needs assessments of children has risen markedly, with only a brief plateau in 2019‑2020. The number of assessments has increased from approximately 53 000 in 2015 to around 162 000 in 2024 (Figure 6.1, Panel A).
In 2024, the sizes of diagnostic groups among children requiring care were far from equal. Three diagnostic groups clearly stand out: F90 (hyperkinetic disorders), F84 (pervasive developmental disorders), and F83 (mixed specific developmental disorders). Hyperkinetic disorders account for roughly 21% of all children with care needs. A diagnosis of pervasive developmental disorders, which includes autism, represents the second largest group at around 15%, followed closely by mixed specific developmental disorders at approximately 14% (Figure 6.1, Panel B). All other common diagnoses each represent fewer than 5% of children with care needs.
The distribution of care levels among children closely mirrors that of the overall population assessed for care needs (Figure 6.2). Approximately 10% of all assessed individuals and children are determined ineligible for Care Allowance. Most recipients, children and adults alike, are classified under care Level 2 or level 3, with Level 2 being most common. Care Level 5 is by far the least frequent among both children and all assessed individuals. However, children are slightly less likely to be classified in the higher care levels (4 and 5), and more frequently fall into Level 2 (around 37%) or Level 3 (approximately 28%).
Assessments of children (aged 0‑18) to determine care needs and most common diagnoses among children requiring care
Note: F90: Hyperkinetic Disorders; F84: Pervasive Developmental Disorders; F83: Mixed Specific Developmental Disorders; F80: Specific Developmental Disorders of Speech and Language; F89: Unspecified Disorder of Psychological Development; Q90: Down Syndrome; E10: Type 1 Diabetes Mellitus; P07: Disorders related to short gestation and low birth weight, not elsewhere classified; F98: Other behavioural and emotional disorders with onset usually occurring in childhood and adolescence; G80: Infantile Cerebral Palsy.
Source: Medizinischer Dienst Bund (2025[16]), Report Pflegebedürftigkeit 2025, https://md-bund.de/themen/pflegebeduerftigkeit-und-pflegebegutachtung/report-pflegebeduerftigkeit.html.
Distribution of Care Allowance recipients by care level, for all people and children (ages 0‑18), 2024
Note: Levels 1‑5: Level of care needs on a 100‑points scale, e.g. Level 1=12.5‑27 points and Level 5=90‑100 points. Those “not in need of care” do not receive a Care Allowance.
Source: Medizinischer Dienst Bund (2025[16]), Report Pflegebedürftigkeit 2025, https://md-bund.de/themen/pflegebeduerftigkeit-und-pflegebegutachtung/report-pflegebeduerftigkeit.html.
Integration Assistance offers funding for disability-related services
In addition to Care Allowance, children with ASD and their families can access Integration Assistance (Eingliederungshilfe), which serves a different purpose: to cover the costs of necessary disability-related services and supports. Unlike Care Allowance, Integration Assistance is not organised into predefined levels but fully individually tailored. The exact scope and amount of support a child or adult receives – since the benefit is accessible across all ages – depends entirely on their assessed needs (betanet, 2025[17]).
In contrast to Care Allowance, Integration Assistance is partially means-tested, although thresholds are set at comparatively lenient levels. For Integration Assistance under Germany’s Social Code (Sozialgesetzbuch, SGB) IX, income and assets of parents are considered if they exceed certain thresholds. Many support services for children covered by Integration Assistance under SGB IX are exempt from co-payments. For Integration Assistance under SGB VIII, parents of children under the age of 18 are not required to contribute financially to outpatient services, while co-payments for inpatient or daycare services may be requested depending on household income (betanet, 2025[17]).
What further distinguishes Integration Assistance from Care Allowance, as well as from many comparable benefits in other countries, is that it is not strictly a cash allowance. It may be provided as an in-kind benefit, such as an integration aide in school or autism-specific therapies, or alternatively as a financial benefit. Eligible individuals can therefore choose between receiving services directly or obtaining a personal budget (Persönliches Budget), a self-managed monthly payment capped at the cost of equivalent publicly funded services, allowing them to purchase supports privately (Bundesministerium für Arbeit und Soziales, n.d.[18]). This flexible structure of Germany’s Integration Assistance aims to empower individuals with disability by offering greater autonomy and choice over both the provider and the manner in which their support is delivered.
Integration Assistance for children is accessible through two different channels
Children with ASD may access Integration Assistance under two different statutory frameworks and correspondingly different administrative bodies depending on the type of disability identified. A child with ASD is typically covered under Germany’s Social Code (SGB) VIII and receiving Integration Assistance via the Youth Welfare Office (Jugendamt). Integration Assistance under SGB VIII applies exclusively to children and young adults with mental disorders, including ASD, generally up to age 21 and in exceptional cases up to age 27. Where a child with ASD also has a physical and/or intellectual disability, access to Integration Assistance shifts to SGB IX, with the competent authority varying across federal states. Adults, typically from age 21 onward, are covered under SGB IX regardless of disability type (betanet, 2025[17]).
Eligibility for Integration Assistance under SGB VIII requires that the child has a mental or behavioural disorder that significantly impairs, or is expected to impair, social participation for more than six months. A formal medical diagnosis, including the relevant ICD‑10 code, must be provided to confirm the disorder. Such a diagnosis of a mental disorder must be issued by one of the following qualified professionals (betanet, 2025[17]):
a doctor specialising in child and adolescent psychiatry and psychotherapy,
a child and adolescent psychotherapists,
a psychotherapist with additional training in the treatment of children and adolescents, or
a doctor or psychotherapist with experience in mental disorders in children and adolescents.
For ASD specifically, the diagnosing clinician must also confirm that no physical or intellectual disability is present to establish the Youth Welfare Office’s jurisdiction under SGB VIII rather than SGB IX. However, a diagnosis alone is insufficient (betanet, 2025[17]). The Youth Welfare Office must additionally determine whether the child’s mental disorder results in current or impending participation restrictions (Teilhabebeeinträchtigung), such as difficulties in attending school or engaging in social and leisure activities and identify the specific support needs. This assessment is carried out in a consultation with the child, their parents, and ideally the diagnosing physician, and may include input from other professionals such as therapists and teachers as well as relevant documentation, such as school reports. The outcome of the assessment and consultation is a Help Plan (Hilfeplan) defining the child’s support needs, goals, and the services required to ensure participation in everyday life on an equal basis with others. Progress is reviewed in regular follow-up meetings where adjustments to the Help Plan may be made (betanet, 2025[19]).
The application procedure for Integration Assistance under SGB IX for children with ASD and co‑occurring physical and/or intellectual disability is largely similar, but the needs assessment is somewhat more standardised and comprehensive. In addition to requiring a formal medical diagnosis, it also entails a collaborative in-person process between social workers, the child, and their parents, drawing on medical, psychological, and educational documentation to determine participation restrictions and necessary supports, including their type and frequency. As under SGB VIII, professionals working closely with the child may be invited to contribute. The assessment is strongly person-centred, based on the ICF framework, and focusses on how the child’s impairment affects their daily life – in areas, such as self-care, mobility, communication, learning, and social interaction – and on services and supports that are required (betanet, 2025[20]). For both SGB VIII and SGB IX, comprehensive reassessments should take place regularly and at least every two years to ensure support remains appropriate and responsive to the child’s developmental progress.
A considerable number of children benefit from Integration Assistance
Over recent years, the number of children with disability receiving Integration Assistance under both SGB IX and SGB VIII has risen steadily. The annual number of children supported under SGB IX has grown from roughly 274 000 in 2020 to about 325 000 in 2024 (Figure 6.3). Similarly, children benefiting from Integration Assistance under SGB VIII at the end of each year increased from about 92 000 in 2019 to 118 000 in 2023. Adding SGB IX and SGB VII entitlements together, this is about three times the number receiving a Care Allowance. While growth under SGB IX appears to be slowing, the number of children supported under SGB VIII (i.e. those with mental disorders) continues to rise sharply. Notably, the share of children among all individuals receiving Integration Assistance under SGB IX has remained relatively stable at around 30% (Panel A, Figure 6.3). It is also important to mention that a major reform reassigned Integration Assistance from SGB XII to SGB IX in the year 2020, potentially affecting data availability in 2020.
In parallel to the growing uptake of Integration Assistance, annual costs under SGB IX for adults and children together have steadily increased in recent years, from EUR 20.8 billion in 2020 to EUR 28.7 billion in 2024, an increase of about 37.7% (Federal Statistical Office Germany – Destatis, 2025[21]).
Children and young adults receiving Integration Assistance under SGB IX and SGB VIII
SGB: Sozialgesetzbuch (Social Code)
Note: Children aged 0‑17 (Panel A); children and young adults up until 27 years of age but typically only until 21 years (Panel B).
Source: For Integration Assistance under SGB VIII: Federal Statistical Office Germany – Destatis (2025[22]), Erzieherische Hilfen/Beratungen: Deutschland, Jahre, Geschlecht, Migrationshintergrund, Art der Hilfe, https://www-genesis.destatis.de/datenbank/online/table/22517-0002/search/s/MjI1MTctMDAwMg%3D%3D. For Integration Assistance under SGB IX: Federal Statistical Office Germany – Destatis (2025[23]), Empfänger von Eingliederungshilfe: Deutschland, Jahre, Geschlecht, Altersgruppen, Leistungsarten, https://www-genesis.destatis.de/datenbank/online/table/22161-0001/search/s/MjIxNjEtMDAwMQ%3D%3D.
Integration Assistance encompasses a wide range of supports that aim to enable persons with disability to participate fully in society. These services may be medical (such as, e.g. therapies not covered by health insurance), educational (such as school integration aides), vocational, mobility-related, or social-assistive (e.g. personal assistance). For children with intellectual and/or physical disability who receive Integration Assistance under SGB IX, the most frequently accessed supports are those related to social participation and education, i.e. services which are not covered through other instruments or institutions (Figure 6.4). Medical rehabilitation services, though among the top five services, are comparatively rare as they are in most cases covered by health insurance.
Most common types of services provided to children (aged 0‑17) under Integration Assistance (SGB IX), 2024
SGB: Sozialgesetzbuch (Social Code)
Source: Federal Statistical Office Germany – Destatis (2025[23]), Empfänger von Eingliederungshilfe: Deutschland, Jahre, Geschlecht, Altersgruppen, Leistungsarten, https://www-genesis.destatis.de/datenbank/online/table/22161-0001/search/s/MjIxNjEtMDAwMQ%3D%3D.
The relatively limited use of medical rehabilitation services through the Integration Assistance is explained by the role of Germany’s statutory health insurance system. Statutory health insurers cover medically necessary rehabilitation services, such as occupational, speech and language therapy, and psychotherapy for children with disability, including those with ASD. This health insurance pathway is in fact the primary mechanism for accessing paramedical therapies in Germany. To receive therapy, a child must obtain a doctor’s prescription specifying their diagnosis, how it affects their functioning, and the type, frequency, and duration of therapy required. With this prescription, the child can access the appropriate therapeutic provider, and all prescribed services are covered by health insurance (Lebenshilfe, 2025[24]; 2025[25]). As a result, the amount of therapy a child receives is driven mainly by their assessed individual needs – and, in practice, the availability of providers and associated waiting times – rather than any diagnosis-based caps on service hours.
Children seeking access to specialised therapies – such as music therapy, therapeutic horseback riding, or autism-specific interventions like Applied Behaviour Analysis (ABA) delivered in dedicated autism centres – would typically not have these supports reimbursed by statutory health insurance, unlike standard therapies. Families must therefore either pay out of pocket or apply for Integration Assistance, which is designed to fund individually tailored support measures for persons with disability, including those with ASD. During the assessment process, if the respective individual and legal prerequisites are met and the responsible social worker determines these specialised therapies would meaningfully promote the child’s autonomy and/or support their social inclusion and participation, individually tailored support measures can be approved as in-kind services or as part of their Personal Budget – depending on whether the parents prefer direct provision of services or a budget to organise support themselves.
Another common pathway for accessing therapeutic support in Germany is through the education system, particularly within special education schools. These schools often provide therapies on-site and integrated into the student’s daily schedule. A multi-disciplinary school team typically identifies the child’s needs, after which the school authority makes recommendations regarding appropriate support. Responsibility for funding depends on the nature of the therapy: if it is deemed an educational intervention, costs are usually covered by the school or regional education budgets or even the Integration Assistance, whereas therapies classified as medical interventions are financed by statutory health insurance. The school then develops an individual support plan specifying the exact type and frequency of therapy, based on both the medical prescription and the school’s understanding of the child’s educational needs. For medical interventions, the same requirements apply as for all other interventions reimbursed by the healthcare system, as described above – namely, a confirmed medical diagnosis and a doctor’s prescription.
The two main schooling options available to children with special educational needs (SEN) in Germany are enrolment in a regular school or in a special education school (Förderschule). Because responsibility for education policy lies with the individual federal states, there are no nationwide regulations governing how exactly school placement and support measures for children with SEN should be determined. When parents or teachers suspect that a child requires more extensive support than what is currently provided at school, they can request a SEN assessment (Sonderpädagogisches Gutachten) from the competent school authority. These assessments are typically led by a SEN Service (Sonderpädagogischer Dienst) of the school authority (sofatutor-Magazin, n.d.[26]; Inklusion und Schule, n.d.[27]).
Assessments may be carried out by a single specialist or a multi-disciplinary team that can include regular and special education teachers, and where needed, additional professionals such as medical or psychological experts. The evaluation draws on classroom observations, discussions with the child and parents, and a review of relevant documentation, including previous school and medical reports. It typically also involves functional tests across areas such as learning, communication, socio‑emotional development, motor skills, and self-care. A formal medical diagnosis is not usually required, as placement and support decisions are based primarily on the child’s assessed educational needs. At the end of the process, the school authority issues recommendations on appropriate special support measures and, where relevant, on whether placement in a special education school is advised (sofatutor-Magazin, n.d.[26]). Parents play a crucial role throughout the process, including in the final decision making.
A wide range of support measures may be made available to children with SEN, including integration assistants, assistive technologies, adapted curricula and teaching methods, and on-site therapy. When required supports, such as an integration assistant, cannot be provided directly by the school, families may utilise Integration Assistance to cover the associated costs. As shown in Figure 6.4, educational supports are among the most frequently funded services through Integration Assistance for children. Integration Assistance can also finance additional therapeutic interventions at school and other educational support where school-based provision is insufficient.
Children with SEN increasingly attend regular schools but the pace of change is slow
Since 2017/18, the number of students with SEN in Germany has increased from approximately 496 000 to around 595 000 in 2023/24 (Figure 6.5, Panel A). The sharpest rise has occurred among students with SEN enrolled in regular schools, reaching about 262 000 in 2023/24. This number still falls short of those enrolled in special education schools, which stood at roughly 333 000 in 2023/24. Thus, while there is a gradual shift toward inclusion in regular schools, the transition to fully inclusive education is ongoing.
Students with SEN by school setting and focus area of support at special schools, Germany (2024/25)
SEN: Special Educational Needs
Note: Data available only for special schools in Saarland. No data available for some mainstream schools for 2017 in Bavaria. Pupils with SEN are statistically recorded as pupils who receive special educational support, regardless of whether a SEN status has been formally identified or not. The total number of students and their distribution across settings thus differ from those shown in Figure 4.1, which is based on data from the European Agency for Special Needs and Inclusive Education and includes only students with an official SEN decision.
Source: Federal Statistical Office Germany – Destatis (2025[28]), Pupils with special educational support: Germany, school year, type of school, main areas of support, https://www-genesis.destatis.de/datenbank/online/table/21111-0007/search/s/MjExMTEtMDAwNw%3D%3D.
The most common focus areas of support of students enrolled in special education schools in 2024/25 are “Learning” and “Intellectual Development”, accounting for about 113 000 and 101 000 students, respectively (Figure 6.5, Panel B). The SEN assessment described above determines the primary focus of educational support for each child – the focus area of support (Förderschwerpunkt) – which falls into one of seven categories: Learning, Language, Hearing, Seeing, Intellectual Development, Emotional and Social Development, and Physical and Motor Development. Depending on the child’s identified focus area, schools are provided with additional resources specifically allocated to support that child’s needs.
Germany’s experience reflects a gradual but significant shift toward a rights-based approach to supporting individuals with autism. Over the past two decades, the country has strengthened its legal framework, aligned disability policy with international standards, and expanded access to financial and practical supports tailored to assessed needs rather than solely to medical diagnoses. The introduction of comprehensive clinical guidelines for autism diagnosis and therapy has contributed to greater consistency in service provision, while reforms to available benefits, Care Allowance and Integration Assistance, have improved access for families. At the same time, persistent challenges remain, including the absence of reliable population prevalence data and the slow transition to inclusive education. Continued efforts to enhance implementation of existing guidelines, ensure equitable access to supports across regions, and maintain a strong focus on participation and autonomy will be essential to sustaining Germany’s progress in meeting the needs of children with ASD and their families.
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