In this interventional, pilot clinical trial investigators will stimulate the dorsolateral prefrontal cortex (DLPFC) in patients with Autism and ADHD. The goal of the study is to improve Cognition and Executive Functions associated with this brain region and, consequently, ameliorate the core symptoms of the disorders. Specifically, the primary purpose is to establish the efficacy, safety, and tolerability of TMS in pediatric patients with ASD and ADHD. Concurrently, the research aims to uncover the impact of TMS on particular biomarkers associated with the development of these disorders and validate the hypothesis suggesting that the BDNF gene polymorphism (Val66Met) could influence an individual's susceptibility to TMS. Participants will be randomized into the active group and placebo group, to guarantee a real assessment of the impact of neurostimulation on the cognitive, behavioral, and biochemical parameters. Participants will be asked to complete a neuropsychological evaluation and a biological sample collection before and after TMS treatment, and 1-month post-treatment completion.
BACKGROUND ASD and ADHD are complex neurodevelopmental disorders with increasing prevalence worldwide. The neurobiology of ASD and ADHD reveals a complex picture of altered excitation-inhibition (E/I) balance, aberrant neuronal activity, and disorganization of brain networks. While cognitive and behavioral abnormalities in ASD are related to excessive excitability (due to altered cortex cytoarchitecture), especially at the prefrontal lobes, ADHD patients show reduced activation in the right VLPFC and DLPFC. Neuroinflammation, glutamate imbalance, and kynurenines pathway (KP) dysfunction seem to play a key role in the pathogenesis of these disorders, creating a self-sustaining auto-toxic loop. Treatment options for these disorders are limited, mainly focusing on early behavioral interventions. While for ASD there are no specific pharmacological treatments to address the core symptoms, psychostimulants are considered the most effective therapy for patients with ADHD. Unfortunately, various side effects and the potential for abuse with no reduction in symptom severity in long-term use can restrict its administration. In this scenario, transcranial magnetic stimulation (TMS) could emerge as a reliable therapeutic option. TMS involves magnetic stimulation of the brain to cause long-term changes in excitability and neurochemical activity, healing the key neurobiological alterations described above. Although shreds of evidence on its potential use in ASD-ADHD treatment, there are still critical challenges that limit its use in clinical practice. One of the big issues is the problem of heterogeneity of the results and the stimulation protocols used in current studies. Many factors influence the efficacy of TMS, including the stimulation parameters and the functional state of the targeted region during stimulation. Also, the psychotropic drugs taken by enrolled patients may affect TMS outcomes, as they cause long-term changes in synaptic and excitatory balance. The brain-derived neurotrophic factor (BDNF) gene polymorphism (Val66Met) has been considered a critical contributing factor to individual susceptibility to TMS. BDNF is, indeed involved in early and long-term potentiation, particularly in hippocampal synapses, and its polymorphism has been shown to affect different cognitive functions. According to the most recent data, heterozygous Val/Met individuals were less susceptible to TMS effects. Finally, another crucial weakness is the lack of longitudinal follow-up, at a well-defined point in time, later neurostimulation. This avoids critical questions regarding possible predictors of outcome (e.g., genetic profiling), length of persistence of benefits, assessing outcome according to the severity of phenotypic presentation, and utility of booster session. AIMS and OBJECTIVES The primary aim of the study is to establish the efficacy, safety, and tolerability of TMS in pediatric patients with ASD and ADHD. Key objectives include: 1. Evaluating TMS impact on core symptoms, cognition, and executive functions. 2. Analyzing changes in peripheral biomarkers, such as neurotransmitters, kynurenines, and neurotrophins following TMS. 3. Investigating the role of BDNF gene polymorphism (Val66Met) in TMS individual susceptibility. 4. Identifying clinical profiles and individual factors influencing TMS efficacy (such as cognitive level, ongoing therapies, age, sex, neuropsychiatric comorbidities, clinical severity, etc.). 5. Establishing a longitudinal follow-up to assess predictors of outcome, persistence of benefits, and the utility of booster sessions. METHODOLOGY It is expected to recruit for this study at least 80 children, divided into 2 groups: 40 children with ASD, and 40 children with ADHD, both of them will be randomly divided into the active group (real TMS stimulation) and the Sham group (placebo stimulation). In case of the inferiority of the sample, due to the difficulty of recruitment, investigators will proceed to administer the active and sham stimulation to the same patients, alternatively, in two different moments, after a proper wash-out. It has been proposed 36-40 months to complete the whole study. Recruitment of participants will be carried out at the Neuropsychiatry Unit for Children and Adolescents, General Hospital "Riuniti" of Foggia. It has been planned to identify children among hospitalized patients who need a first diagnosis of ADHD and ASD or who need to be followed up. Written informed consent will then be requested from parents, legal tutors, and children wherever possible. * Study Assessment This study will be articulated according to the following phases: 1. Collecting and managing biomaterials Peripheral blood, saliva, and urine samples will be collected before and after neurostimulation. To verify the impact of TMS on serum and molecular profile in children with neurodevelopmental disorders, we will provide a third biological sample, one month after the last neurostimulation session. The following biomarkers will be assessed: • Tryptophan and its catabolites: KINA, QUIN, 3-HK, etc. • Glutamate, GABA (γ-Aminobutyric acid), Serotonin, and Dopamine. * Plasmatic BDNF * Inflammatory biomarkers: cortisol, IL-6, IL-1β, TNF-α, TSH, FT3, FT4, Protein-C-reactive (PCR), ferritin. A small amount of blood will be used to genotype BDNF gene polymorphism (Val66Met). 2. Clinical and Neuropsychological assessment Parents will be asked to complete a set of questionnaires and interview measures designed to assess symptoms of ASD and ADHD, such as: • Vineland Adaptive Behavior Scales - Second Edition. • Conners 3 • The Child Behavior Checklist (CBCL). • Autism Diagnostic Interview-Revised (ADI-R) • Social Communication Questionnaire (SCQ). Participants will be asked to complete a battery of cognitive, neuropsychological, and play-based assessments, including: • Autism Diagnostic Observation Schedule-2 (ADOS-2). * Wechsler Intelligence Scale for Children IV Ed. * Leiter International Performance Scale-Revised. * Developmental Neuropsychological Assessment, second edition (NEPSY-II) * M-ABC (Movement Assessment Battery for Children) * Children's Depression Inventory 2™ (CDI 2) * Multidimensional Anxiety Scale for Children Second Edition™ (MASC 2) Neuropsychological evaluation will be conducted at three different moments, before and after the neurostimulation and 1 month after the last stimulation. 3. EEG data collection and Neurostimulation The Department of Clinical and Experimental Medicine-University of Foggia will perform TMS neurostimulation. For all participants (both active and sham groups), EEG data will be recorded two times, 30 min before TMS and within 30 min after the last stimulation. The participants will sit in a quiet room, awake and relaxed, with their eyes open. During the data-recording process, 5-10 minutes of resting-state EEG data will be recorded from 32 electrodes positioned according to the 10-10 International System (BrainVision, Brain Products GmbH, Germany). Matlab and the package EEG lab will be used for offline data analysis. TMS parameters will be tailored to each disorder's neurobiology. - ASD Protocol The Casanova-Sokhadze research group's TMS protocol will be used because it is the most widely replicated protocol in the pediatric population, with good safety and tolerability as well as fair efficacy. For repetitive TMS administration, we will use a Magstim R2 stimulator (Magstim Co, UK) with a 70-mm wingspan figure-eight coil, handle oriented approximately 45° from the midline. The neuronavigation system will be utilized to correctly identify the stimulation site (PFC/DLPFC) for every subject. Since it is difficult to treat patients with autism, to avoid their discomfort researchers hypothesize establishing the location of TMS stimulation, through the use of anatomical landmarks corresponding to the scalp regions used for F3 and F4 EEG electrode placement in the 10-20 international system. Individual MT will be assessed for each hemisphere at the beginning of treatment (L DLPFC, R DLPFC, L + R DLPFC). Participants will receive 18 rTMS treatment with Fig8 coil twice weekly (9 weeks). The rTMS will be administered with the following stimulation parameters: 1Hz frequency, 90% MT, 180 pulses per session with 9 trains of 20 pulses each with 20-30s intervals between the trains. The initial 6 times, rTMS sessions will be administered over the left DLPFC, followed by 6 sessions targeting the right DLPFC, and an additional 6 treatments will be done bilaterally. The sham rTMS group will receive the same process but the figure-eight coil will be placed vertically on the scalp with no magnetic field penetrated through the skull. The stimulation parameters will be the same as those of the real rTMS. The environmental conditions will be the same for each test (comfortable armchair, quiet room, elbow positioned at 90◦ flexion). Participants will be required to use earplugs during TMS sessions. The selection of 90% of the Motor Threshold (MT) has been chosen as a precautionary measure to reduce the risk of seizure in this study population, while the choice of 1 Hz of stimulation is based on the evidence that low-frequency improves cortex E/I imbalance. \- ADHD protocol Participants will receive 18 rTMS treatments with Fig-8 coil twice per week (9 weeks). The rTMS will be administered with the following stimulation parameters: 5 (or 10) Hz frequency, 90% MT, 180 pulses per session with 9 trains of 20 pulses each with 20-30 s intervals between the trains. The initial six times, rTMS sessions will be administered over the left DLPFC, followed by 6 sessions targeting the right DLPFC, and an additional 6 treatments will be done bilaterally (over the left and right DLPFC). For the sham rTMS group, the coil will be simply placed perpendicular to the scalp of the stimulation site. The stimulation parameters will be the same as those of the real rTMS. Studies on children and adolescents with ADHD are significantly fewer than those with ASD. So it is difficult to find a validated and often replicated TMS protocol. For the ADHD population, high-frequency stimulation will be used since it was noted that high frequency can significantly improve ADHD symptoms. It has been also shown that TMS might produce a similar effect on the dopamine system as D-amphetamine a well-known psychostimulant. It has been decided to select 90% of the MT to avoid seizure risk to patients. At the end of every single session, a questionnaire regarding side effects will be administered to all participants. BENEFITS AND IMPLICATIONS The study aims to establish a standardized TMS protocol for pediatric ASD and ADHD, addressing heterogeneity in methodology and outcomes. Since it has been demonstrated that younger age is a predictor of better response to TMS therapy (as children's brains are more plastic than adults), intervening in the pediatric population might result in more effective effects. Insights into neurotransmitter and biochemical modulation, BDNF's role, and TMS susceptibility can guide personalized interventions. The research could modernize treatment approaches, offering a noninvasive, targeted therapy for these complex disorders. Additionally, the study might identify potential biomarkers for diagnostic and therapeutic purposes. ETHICAL CONSIDERATIONS AND CONFIDENTIALITY The study has received ethical approval and complies with the Declaration of Helsinki. Personal data will be securely stored, anonymized, and accessible only to authorized personnel. Stringent measures will be taken to ensure participant confidentiality throughout the study.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
QUADRUPLE
Enrollment
80
Pediatric patients with ASD and ADHD will be randomized both in active and sham groups.
Neuropsychiatric Unit for Child and Adolescent, at General Hospital "Riuniti" of Foggia, University of Foggia
Foggia, Italy
RECRUITINGDetermining the impact of rTMS on Cognitive Functioning in Real Groups versus Sham Groups, through changes in scores of NEPSY-II sub-scales
The NEPSY-II is a comprehensive neuropsychological battery for children and adolescents ages 3-16. It contains 32 subtests, which are divided into six domains of cognitive functioning: Attention and Executive Functioning; Language; Memory and Learning; Sensorimotor; Social Perception; and Visuospatial Processing. Scores are categorized into standard scores (which usually range from 1 to 19 for each subtest), percentile ranks, and age-equivalent scores. Results are compared to a normative sample to assess a child's performance. Higher scores generally indicate better performance, while lower scores may suggest areas of concern or developmental delay.
Time frame: Baseline; Post rTMS (9 weeks after baseline); One month follow-up (4 weeks after rTMS)
Determining the impact of rTMS on Depression in Real Groups vs. Sham Groups, through changes in CDI and MASC scores
The CDI is a self-report questionnaire designed to assess depressive symptoms in children and adolescents. Each item is rated on a scale, often from 0 to 2 or 0 to 3, with higher scores indicating more severe depressive symptoms. The total score is calculated by summing the individual item scores. Cutoff scores are used to categorize depression severity (e.g., mild, moderate, severe).
Time frame: Baseline; Post rTMS (9 weeks after baseline); One month follow-up (4 weeks after rTMS)
Determining the impact of rTMS on Motor Skills and Coordination in Real Groups vs. Sham Groups, through changes in M-ABC scores
The Movement Assessment Battery for Children (M-ABC) is a motor assessment tool for children aged 3 to 16. The test includes various motor tasks grouped into three categories: manual dexterity, aiming and catching, and balance. Trained examiners administer the tasks and assign scores based on the child's performance. Scores are typically assigned on a scale of 0 to 5 for each task, with higher scores indicating better motor performance. The overall score is calculated by summing the individual task scores within each category. Lower overall scores may suggest motor skill difficulties or delays. The M-ABC results are often interpreted in conjunction with the child's age and gender, as motor development can vary among children.
Time frame: Baseline; Post rTMS (9 weeks after baseline); One month follow-up (4 weeks after rTMS)
Determining the impact of rTMS on Emotional and Behavioral Problems in Real Groups vs. Sham Groups, through changes in CBCL scores
The Child Behavior Checklist (CBCL) is a questionnaire completed by parents or caregivers to assess a child's behavioral and emotional problems. Parents or caregivers provide responses to a series of questions about the child's behavior and emotions. Each item is assigned a numerical value based on the caregiver's responses. These values are summed to create raw scores for different scales and subscales within the CBCL. The raw scores are then converted into T-scores. T-scores are standardized scores with a mean (average) of 50 and a standard deviation of 10. These scores allow for comparisons with a normative sample of children of the same age and gender. Typically, scores falling within the range of 30 to 70 are considered within the average range. Scores below 30 may indicate below-average functioning, while scores above 70 suggest above-average or potentially concerning behavior.
Time frame: Baseline; Post rTMS (9 weeks after baseline); One month follow-up (4 weeks after rTMS)
Determining the impact of rTMS on Adaptive Behaviors in Real Groups vs. Sham Groups, through changes in Vineland Scale scores
The Vineland is a structured interview with a parent or caregiver, which assesses adaptive behaviors in four main domains: Communication, Daily Living Skills, Socialization, and Motor Skills (optional). The Vineland uses standard scores percentile ranks, and age-equivalent scores to quantify an individual's level of adaptive functioning. Ratings are typically on a scale with options like "unable," "sometimes," "usually," and "always. These scores are based on the person's performance relative to a normative sample of individuals of the same age. The Vineland provides an overall summary score known as the Adaptive Behavior Composite (ABC) score. It represents an individual's general adaptive functioning across all domains. In addition to the ABC score, the Vineland provides subdomain scores for each of the four main domains, allowing for a more detailed assessment of specific areas.
Time frame: Baseline; Post rTMS (9 weeks after baseline); One month follow-up (4 weeks after rTMS)
Determining the impact of rTMS on ADHD symptoms in Real Groups vs. Sham Groups, through changes in Conners scores
The Conners-3 (Conners 3rd Edition) is a widely used questionnaire for evaluating and measuring ADHD symptoms in children and adolescents. It may be administered to parents, teachers, and sometimes the child or adolescent themselves, depending on their age. The Conners-3 generates standard scores for various scales and indices. These scores are typically presented as T-scores, with a mean of 50 and a standard deviation of 10. T-scores help compare the child's behavior to a normative sample of children of the same age and gender. Higher T-scores indicate more severe symptoms or concerns.
Time frame: Baseline; Post rTMS (9 weeks after baseline); One month follow-up (4 weeks after rTMS)
Determining the impact of rTMS on Anxiety in Real Groups vs. Sham
MASC is a self-report questionnaire designed to assess anxiety symptoms in children and adolescents. Patients rate the frequency of their experiences on a 4-point scale, with higher scores indicating greater anxiety. MASC provides a total anxiety score, reflecting the overall level of anxiety symptoms. Subscale scores may also be considered to examine specific domains of anxiety ( including physical symptoms, harm avoidance, social anxiety, and separation/panic). Higher total scores on MASC indicate more significant anxiety symptoms.
Time frame: Baseline; Post rTMS (9 weeks after baseline); One month follow-up (4 weeks after rTMS)
Determining the impact of rTMS on BDNF in Real Groups vs. Sham Groups, through changes in BDNF serum concentration.
BDNF levels in the plasma will be measured using laboratory techniques such as enzyme-linked immunosorbent assay (ELISA) or immunoassay. These assays use antibodies that specifically bind to BDNF, allowing for quantification. The results of the assay will be analyzed to determine the concentration of BDNF in the plasma sample. This concentration will be reported in picograms per milliliter (pg/mL).
Time frame: Baseline; Post rTMS (9 weeks after baseline); One month follow-up (4 weeks after rTMS)
Determining the impact of rTMS on GABA in Real Groups vs. Sham Groups, through changes in serum concentration.
Neurotransmitter GABA will be dosed in serum at three different points in time (baseline, post-treatment, and 1 month later), to evaluate the effect of rTMS in modulating its concentration. This neurotransmitter will be quantified by HPLC and mass spectrometry. Concentrations will be reported in nanograms per milliliter (ng/mL) or picomoles per milliliter (pmol/mL), depending on the assay's sensitivity.
Time frame: Baseline; Post rTMS (9 weeks after baseline); One month follow-up (4 weeks after rTMS)
Determining the impact of rTMS on glutamate in Real Groups vs. Sham Groups, through changes in serum concentration.
Glutamate will be dosed in serum at three different points in time (baseline, post-treatment, and 1 month later), to evaluate the effect of rTMS in modulating its concentration. This neurotransmitter will be quantified by HPLC and mass spectrometry. Concentrations will be reported in nanograms per milliliter (ng/mL) or picomoles per milliliter (pmol/mL), depending on the assay's sensitivity.
Time frame: Baseline; Post rTMS (9 weeks after baseline); One month follow-up (4 weeks after rTMS)
Determining the impact of rTMS on dopamine in Real Groups vs. Sham Groups, through changes in serum concentration.
Dopamine will be dosed in serum at three different points in time (baseline, post-treatment, and 1 month later), to evaluate the effect of rTMS in modulating its concentration. This neurotransmitter will be quantified by HPLC and mass spectrometry. Concentrations will be reported in nanograms per milliliter (ng/mL) or picomoles per milliliter (pmol/mL), depending on the assay's sensitivity.
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Time frame: Baseline; Post rTMS (9 weeks after baseline); One month follow-up (4 weeks after rTMS)
Determining the impact of rTMS on serotonin in Real Groups vs. Sham Groups, through changes in serum concentration.
Serotonin will be dosed in serum at three different points in time (baseline, post-treatment, and 1 month later), to evaluate the effect of rTMS in modulating its concentration. This neurotransmitter will be quantified by HPLC and mass spectrometry. Concentrations will be reported in nanograms per milliliter (ng/mL) or picomoles per milliliter (pmol/mL), depending on the assay's sensitivity.
Time frame: Baseline; Post rTMS (9 weeks after baseline); One month follow-up (4 weeks after rTMS)
Determining the impact of rTMS on Kynurenines Pathway in Real Groups vs. Sham Groups, through changes in kynurenines serum and urine concentration.
Kynurenines will be extracted from urine, saliva, and plasma, at three different points in time (baseline, post-treatment, and 1 month later). The main goal is to evaluate how TMS intervention influences the Kynurenines pathway, involved in neuroinflammation. Kynurenines level will be measured using high-performance liquid chromatography (HPLC) or mass spectrometry. The results of the assay will provide the concentration of kynurenines in the respective samples, reported in micromoles per liter (µmol/L) or picomoles per milliliter (pmol/mL) depending on the assay's sensitivity.
Time frame: Baseline; Post rTMS (9 weeks after baseline); One month follow-up (4 weeks after rTMS)
Determining the impact of rTMS on inflammatory protein IL-1 in Real Groups vs. Sham Groups, through changes in serum concentration.
IL-1 will be assessed in the serum to evaluate if TMS impacts its level, as ASD and ADHD pathogenesis involves neuroinflammation. To measure IL-1 enzyme-linked immunosorbent assay (ELISA) will be performed. Concentrations will be reported in nanograms per milliliter (ng/mL) or picomoles per milliliter (pmol/mL), depending on the assay's sensitivity.
Time frame: Baseline; Post rTMS (9 weeks after baseline); One month follow-up (4 weeks after rTMS)
Determining the impact of rTMS on inflammatory protein IL-6 in Real Groups vs. Sham Groups, through changes in serum concentration.
IL-6 will be assessed in the serum to evaluate if TMS impacts its level, as ASD and ADHD pathogenesis involves neuroinflammation. To measure interleukin enzyme-linked immunosorbent assay (ELISA) will be performed. Concentrations will be reported in nanograms per milliliter (ng/mL) or picomoles per milliliter (pmol/mL), depending on the assay's sensitivity.
Time frame: Baseline; Post rTMS (9 weeks after baseline); One month follow-up (4 weeks after rTMS)
Determining the impact of rTMS on inflammatory protein TNF-a in Real Groups vs. Sham Groups, through changes in serum concentration.
Inflammatory proteins, including TNF-a, will be assessed in the serum to evaluate if TMS impacts its levels, as ASD and ADHD pathogenesis involves neuroinflammation. To measure interleukin enzyme-linked immunosorbent assay (ELISA) will be performed. Concentrations will be reported in nanograms per milliliter (ng/mL) or picomoles per milliliter (pmol/mL), depending on the assay's sensitivity.
Time frame: Baseline; Post rTMS (9 weeks after baseline); One month follow-up (4 weeks after rTMS)
Determining the impact of rTMS on inflammatory protein CRP (c-reactive protein) in Real Groups vs. Sham Groups, through changes in serum concentration.
Inflammatory proteins, including CRP, will be assessed in the serum to evaluate if TMS impacts its levels, as ASD and ADHD pathogenesis involves neuroinflammation. To measure interleukin enzyme-linked immunosorbent assay (ELISA) will be performed. Concentrations will be reported in nanograms per milliliter (ng/mL) or picomoles per milliliter (pmol/mL), depending on the assay's sensitivity.
Time frame: Baseline; Post rTMS (9 weeks after baseline); One month follow-up (4 weeks after rTMS)
Determining the impact of rTMS on cortisol in Real Groups vs. Sham Groups, through changes in serum and saliva concentration.
Cortisol will be assessed in the serum and saliva at three different points in time. Immunoassays (ELISA) will be used to quantify it. Results will be typically reported in nanograms per milliliter (ng/mL).
Time frame: Baseline; Post rTMS (9 weeks after baseline); One month follow-up (4 weeks after rTMS)