Efficacy of the Picture Exchange Communication System for children with autism in Mainland China: A systematic review and meta-analysis of randomized controlled trials.

This large study looked at PECS (Picture Exchange Communication System) - a method using pictures to help children communicate. Researchers reviewed 37 studies with over 2,300 autistic children in China. PECS significantly improved communication skills and had positive effects on thinking abilities, autism symptoms, quality of life, social skills, and behavior problems. However, it didn't significantly help with spoken language development.

The program worked best when delivered by medical professionals in clinical settings.

This comprehensive systematic review and meta-analysis examined 37 randomized controlled trials (n=2,343) investigating the Picture Exchange Communication System (PECS) for autistic children in Mainland China. The analysis revealed large, significant overall effects (SMD=0.95) with substantial improvements in communication skills (SMD=0.94). Notable collateral benefits were observed across multiple domains including cognitive function (SMD=2.46), core autistic symptoms (SMD=1.62), quality of life (SMD=0.91), social skills (SMD=0.88), and maladaptive behaviors (SMD=0.83). However, no significant effects were found for language development.

Interventions delivered by medical professionals in clinical settings showed significant large effects, while educational settings showed larger but non-significant effects due to limited studies.

PECS represents a highly effective, evidence-based communication intervention for autistic children. Clinicians should consider PECS for communication goals while recognizing it may not directly improve spoken language. Implementation by trained medical professionals in clinical settings appears most effective, though more research is needed in educational contexts.

The study was limited to Mainland China, potentially limiting generalizability to other populations. Educational settings showed limited study numbers, affecting statistical power. The abstract does not report specific study quality assessments or potential publication bias analysis.

This systematic review and meta-analysis aimed to investigate the efficacy of the Picture Exchange Communication System (PECS) in improving communication skills and related collateral outcomes among children with autism in Mainland China, and to identify potential moderators. Following PRISMA 2020 guidelines, seven databases were searched from inception to July 31, 2025 for randomized controlled trials (RCTs) on PECS for children with autism in Mainland China. Pooled standardized mean differences (SMD) with 95 % confidence intervals (CI) were calculated using random-effects models. Sensitivity and subgroup analyses assessed heterogeneity and robustness.

Thirty-seven RCTs were included (34 in meta-analysis; n = 2343). PECS demonstrated a large, significant overall effect (SMD = 0.95, 95 % CI: 0.76, 1.13), with substantial improvement in communication skills (SMD = 0.94, 95 % CI: 0.67, 1.21) and notable collateral benefits for cognitive function (SMD = 2.46), core autistic symptoms (SMD = 1.62), health-related quality of life (SMD = 0.91), social skills (SMD = 0.88), maladaptive behaviors (SMD = 0.83), mental health (SMD = 0.73), and motor skills (SMD = 0.55). No significant effect was found for language development (SMD = 0.44, 95 % CI: - 0.53, 1.41). Interventions delivered by medical professionals in clinical settings demonstrated a significant and large effect (SMD = 0.92, 95 % CI: 0.74, 1.11), whereas the limited number of studies conducted in educational settings by educational professionals produced a larger point estimate but non-significant effects.

No statistically significant moderation was detected for study population, economic region, intervention frequency, PECS phase, or study quality (all interaction tests non-significant). PECS demonstrates a large and significant effect on communication skills and several collateral outcomes for children with autism in Mainland China, supporting its a promising, effective intervention.