Efficacy of the Picture Exchange Communication System for children with autism in Mainland China: A systematic review and meta-analysis of randomized controlled trials.
Across 37 Chinese RCTs, PECS produced large gains in communication and collateral skills for kids with autism—effects biggest when run by medical staff in clinics.
01Research in Context
What this study did
Huang et al. (2026) pooled 37 Chinese randomized trials of PECS. All kids had autism. The team looked at communication plus side benefits like play and self-control.
Only trials run in clinics or hospitals made the cut. Most therapists were medical staff. This gives a clear picture of PECS inside China’s health system.
What they found
PECS came out strong. Kids talked, pointed, and played more. Gains showed up fast and lasted.
The biggest leaps happened when medical staff ran the program in clinic rooms. Home and school settings were not studied here.
How this fits with other research
Leaf et al. (2012) saw the same large communication boost in a world-wide meta of smaller studies. The new Chinese data line up well and add more kids.
Doherty et al. (2018) pushed PECS further by teaching kids to trade pictures with peers, not just adults. That social step builds on the basic gains shown here.
Sun et al. (2013) warned that autism services in China are thin and costly. Huan’s 2026 review now shows PECS is one service that actually works there, giving families a proven option to fight the gap.
Why it matters
If you serve Chinese families, you can now cite local evidence that PECS works. Push for clinic-based sessions when possible and train medical staff first. Even if you work elsewhere, the size of these effects can guide your goal setting and help explain to funders why PECS deserves hours.
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02At a glance
03Original abstract
OBJECTIVE: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.
Research in developmental disabilities, 2026 · doi:10.1016/j.ridd.2025.105190