Meta-analysis: Children with ASD show poorer balance vs. TD peers, SMD -0.66 with observational tools

UNLABELLED: Children and adolescents with autism spectrum disorder (ASD) often present motor difficulties, particularly in postural control, which can affect their autonomy and participation in daily activities. Despite growing interest in balance assessment, there is no comprehensive synthesis comparing balance performance in ASD using both observational and instrumental methods. To compare the static and dynamic balance of children and adolescents with ASD versus typically developing (TD) peers, and to identify the tools most used to assess balance in this population. A systematic review and meta-analysis were conducted following PRISMA guidelines. Six electronic databases were searched to November 2025. Inclusion criteria focused on studies assessing static or dynamic balance in children aged 6-18 with ASD, using validated observational or instrumental tools, and including a TD group. Data extraction, methodological quality assessment, risk‑of‑bias evaluation, and GRADE assessment were performed independently by two reviewers, with discrepancies resolved by discussion or by a third reviewer. Standardized mean differences (SMDs) were calculated using random-effects models, established a priori to account for expected clinical heterogeneity. A total of 34 studies were included in the descriptive synthesis and 16 in the meta-analyses, encompassing 1278 participants (612 ASD, 666 TD). Observational tools (e.g., MABC-2, BOT-2) revealed significantly poorer balance in ASD participants ((SMD = -0.66; 95% CI: -1.07 to -0.25; p = 0.002). Force platform assessments demonstrated larger differences across postural sway measures: mediolateral displacement (stable surface: eyes open SMD = 0.83, eyes closed SMD = 0.56), anteroposterior displacement (stable surface: eyes open SMD = 0.97, eyes closed SMD = 0.27), COM displacement area (SMD = 1.15-7.72 depending on condition), and COM velocity (SMD = 1.00-3.23 depending on condition). Heterogeneity ranged from moderate to very high (I = 0-98%). Sensitivity analyses indicated that some effect estimates, particularly for COM displacement area, were influenced by individual studies. The overall certainty of evidence was low to very low according to GRADE. CONCLUSION: Children with ASD may exhibit poorer static and dynamic balance compared to TD peers using both observational and instrumental assessments. Further high-quality studies are needed to strengthen the evidence base and enhance ecological validity in real-world settings. WHAT IS KNOWN: • Children and adolescents with autism spectrum disorder (ASD) frequently experience balance problems that affect daily functioning and participation. • Earlier reviews have described postural control in ASD but have not examined in depth the instruments used for its assessment. WHAT IS NEW: • This review provides a systematic overview of the clinical and biomechanical tools applied to evaluate balance in ASD. • It also compares the performance of children across different assessment methods, offering practical guidance for clinicians and educators when selecting appropriate measures.