Repetitive transcranial magnetic stimulation for autism spectrum disorder: A systematic review and meta-analysis of treatment regimens, efficacy, and safety.

OBJECTIVE: To evaluated the efficacy and safety of repetitive transcranial magnetic stimulation (rTMS) treatment for autism spectrum disorder (ASD). METHODS: We included RCTs comparing rTMS to sham or non-rTMS controls in individuals with ASD (any age/sex). PubMed, CNKI, and other databases were searched from inception to May 2026 (PROSPERO/CRD420251244998). Random-effects meta-analyses were performed, and certainty of evidence was assessed using GRADE. RESULTS: A total of 53 RCTs (52 references) were included. rTMS significantly improved core ASD symptoms (ABC: SMD=-1.48; CARS: SMD=-0.95; ATEC: SMD=-1.83; SRS: SMD=-0.25; RBS-R: SMD=-0.40) and comorbid symptoms (CSHQ: SMD=-0.96; CBCL: SMD=-0.39), but evidence for executive function remained insufficient. CARS-based subgroup analyses showed no significant differences between low- and high-frequency rTMS (P=0.82) or across stimulation targets (P=0.31). Combining rTMS with special education did not show significant add-on benefits (P=0.34). GRADE indicated low to very low evidence certainty, primarily due to risk of bias (85% open-label), heterogeneity, and publication bias. Adverse events were mild and transient, but over half of the studies (51.9%) did not explicitly report safety data. CONCLUSIONS: Although the meta-analysis suggests rTMS may improve ASD symptoms without serious short-term adverse events, the evidence certainty remains low to very low, and high heterogeneity exists across studies due to variations in protocols, populations, and outcome measures. Therefore, based on current low-certainty evidence, rTMS cannot yet be recommended as routine clinical treatment for ASD. Future research should prioritize double-blind, sham-controlled designs, standardized parameter reporting, and biomarker-guided individualized strategies.