Therapeutic Applications of Noninvasive Neuromodulation in Children and Adolescents

Adverse event monitoring and reporting in pediatric neuromodulatory studies: A systematic review

Neuromodulatory interventions are relatively novel and approaches to studying harms and tolerability have varied. Using a checklist based on guidelines from Good Clinical Practice and the Harms Extension of the CONSORT (Consolidated Standards of Reporting Trials) Statement, we identified how adverse events are measured, assessed, and reported in studies evaluating neuromodulation for the treatment of mental and neurodevelopmental disorders among children and adolescents. A systematic literature review identified 56 experimental and quasi-experimental studies evaluating transcranial magnetic stimulation (TMS), transcranial alternating (tACS) or direct (tDCS) current stimulation, transcranial pulse stimulation (TPS), and vagus or trigeminal nerve stimulation (VNS or TNS). For 22 studies (39%), the types of adverse events to be monitored were identified, and for 31 studies (55%), methods for collecting adverse event data were described. Methods for assessing adverse events were less commonly described with 23 studies (41%) having details on assessing event severity, and 11 studies (20%) having details on assessing event causality. Among 31 studies with reported results, headache, skin irritation, and general pain or discomfort were the most reported across studies. Seizure, untoward medical occurrences, and intracranial bleeding, edema, or other intracranial pathology were considered serious events, but these events were not reported as occurring in any results-based papers. Taken together, the findings from this review indicate that most studies of pediatric neuromodulatory interventions did not include descriptions of adverse event monitoring and evaluation. Comprehensive event monitoring and reporting across studies can significantly augment the current knowledge base.

A systematic review of the neurobiological effects of theta-burst stimulation (TBS) as measured using functional magnetic resonance imaging (fMRI)

Theta burst stimulation (TBS) is associated with the modulation of a range of clinical, cognitive, and behavioural outcomes, but specific neurobiological effects remain somewhat unclear. This systematic literature review investigated resting-state and task-based functional magnetic resonance imaging (fMRI) outcomes post-TBS in healthy human adults. Fifty studies that applied either continuous-or intermittent-(c/i) TBS, and adopted a pretest-posttest or sham-controlled design, were included. For resting-state outcomes following stimulation applied to motor, temporal, parietal, occipital, or cerebellar regions, functional connectivity generally decreased in response to cTBS and increased in response to iTBS, though there were some exceptions to this pattern of response. These findings are mostly consistent with the assumed long-term depression (LTD)/long-term potentiation (LTP)-like plasticity effects of cTBS and iTBS, respectively. Task-related outcomes following TBS were more variable. TBS applied to the prefrontal cortex, irrespective of task or state, also produced more variable responses, with no consistent patterns emerging. Individual participant and methodological factors are likely to contribute to the variability in responses to TBS. Future studies assessing the effects of TBS via fMRI must account for factors known to affect the TBS outcomes, both at the level of individual participants and of research methodology.

Individual brain regulation as learned via neurofeedback is related to affective changes in adolescents with autism spectrum disorder

BACKGROUND

Emotions often play a role in neurofeedback (NF) regulation strategies. However, investigations of the relationship between the induced neuronal changes and improvements in affective domains are scarce in electroencephalography-based studies. Thus, we extended the findings of the first study on slow cortical potential (SCP) NF in autism spectrum disorder (ASD) by linking affective changes to whole-brain activity during rest and regulation.

METHODS

Forty-one male adolescents with ASD were scanned twice at rest using functional magnetic resonance imaging. Between scans, half underwent NF training, whereas the other half received treatment as usual. Furthermore, parents reported on their child's affective characteristics at each measurement. The NF group had to alternatingly produce negative and positive SCP shifts during training and was additionally scanned using functional magnetic resonance imaging while applying their developed regulation strategies.

RESULTS

No significant treatment group-by-time interactions in affective or resting-state measures were found. However, we found increases of resting activity in the anterior cingulate cortex and right inferior temporal gyrus as well as improvements in affective characteristics over both groups. Activation corresponding to SCP differentiation in these regions correlated with the affective improvements. A further correlation was found for Rolandic operculum activation corresponding to positive SCP shifts. There were no significant correlations with the respective achieved SCP regulation during NF training.

CONCLUSION

SCP NF in ASD did not lead to superior improvements in neuronal or affective functioning compared to treatment as usual. However, the affective changes might be related to the individual strategies and their corresponding activation patterns as indicated by significant correlations on the whole-brain level. Trial registration This clinical trial was registered at drks.de (DRKS00012339) on 20th April, 2017.

Functional outcomes of extended-release methylphenidate and atomoxetine in children: retrospective chart analysis

Background

Recent guidelines emphasize the importance of functional outcomes in children with attention-deficit/hyperactivity disorder (ADHD). Here, we assess the functional outcomes of the oral delivery system of osmotic-release methylphenidate (OROS-MPH) and atomoxetine (ATX) from the retrospective review of the chart for the last 2 years in the clinic.

Results

Linear mixed-effects models were performed with outcome measures of difference in ADHD symptoms and functional impairment. After 9–12 weeks, OROS-MPH and ATX were statistically equivalent for total Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P) scores (difference in slope is β = 0.004, p = 1.000). However, OROS-MPH was superior to ATX in terms of school domain (difference in slope is β = 0.139, p < 0.001); ATX was superior in the family domain (slope difference in slope is β = 0.103, p < 0.001). The other domains of functioning both were not responsive to pharmacotherapy and were similar between the two medications.

Conclusions

Optimal management should monitor functional progress in ADHD beyond the core symptoms. As expected, ADHD medications provide a distinct pattern of functional improvement. Pharmacotherapy alone offers promising and reliable outcomes to improve school and family functions in ADHD. Some functional improvements did not respond to the medication; therefore, many of the techniques derived from behavioral interventions should be considered.

Is Repetitive Transcranial Magnetic Stimulation (rTMS) Ready for Clinical Use as a Treatment Tool for Mental Health Targets in Children and Youth?

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive brain stimulation tool with potential for broad application in individuals with neuropsychiatric conditions. As in adults, most rTMS research in youth has focused on treatment-resistant depression. A limited number of rTMS studies have also been conducted in children and youth with primary diagnoses of Autism Spectrum Disorder (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD) or Tourette's syndrome. Across the available rTMS literature, rTMS appears to be well tolerated with few adverse effects reported when applied to child and youth research samples. However, the potential efficacy of rTMS treatment for a variety of targets in children and youth remains unclear, due in part to limitations of the current literature, including studies using diverse protocols, potential for bias in existing clinical trial designs, variability in the research samples, and the use of heterogenous outcome measures. While rTMS is unlikely to take the place of more accessible treatments (e.g., psychopharmacological, psychosocial, psychotherapeutic), rTMS may provide a valuable alternative treatment option, particularly for those individuals where conventional treatments are inaccessible, poorly tolerated, or ineffective. A more robust body of well-designed, controlled trials, is needed in order to clarify rTMS treatment efficacy across relevant neuropsychiatric conditions, optimize treatment protocols, and meet the critical need for novel mental health interventions in children and youth.

Non-invasive brain stimulation and neuroenhancement

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The available data frame with a wide parameter space of tES does not allow an overarching protocol recommendation.

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Established engineering risk-management procedures with regard to manufacturing should be followed.

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Consensus among experts is that tES for neuroenhancement is safe as long as tested protocols are followed.

Attempts to enhance human memory and learning ability have a long tradition in science. This topic has recently gained substantial attention because of the increasing percentage of older individuals worldwide and the predicted rise of age-associated cognitive decline in brain functions. Transcranial brain stimulation methods, such as transcranial magnetic (TMS) and transcranial electric (tES) stimulation, have been extensively used in an effort to improve cognitive functions in humans.

Here we summarize the available data on low-intensity tES for this purpose, in comparison to repetitive TMS and some pharmacological agents, such as caffeine and nicotine. There is no single area in the brain stimulation field in which only positive outcomes have been reported. For self-directed tES devices, how to restrict variability with regard to efficacy is an essential aspect of device design and function. As with any technique, reproducible outcomes depend on the equipment and how well this is matched to the experience and skill of the operator. For self-administered non-invasive brain stimulation, this requires device designs that rigorously incorporate human operator factors. The wide parameter space of non-invasive brain stimulation, including dose (e.g., duration, intensity (current density), number of repetitions), inclusion/exclusion (e.g., subject’s age), and homeostatic effects, administration of tasks before and during stimulation, and, most importantly, placebo or nocebo effects, have to be taken into account. The outcomes of stimulation are expected to depend on these parameters and should be strictly controlled. The consensus among experts is that low-intensity tES is safe as long as tested and accepted protocols (including, for example, dose, inclusion/exclusion) are followed and devices are used which follow established engineering risk-management procedures. Devices and protocols that allow stimulation outside these parameters cannot claim to be “safe” where they are applying stimulation beyond that examined in published studies that also investigated potential side effects.

Brain stimulation devices marketed for consumer use are distinct from medical devices because they do not make medical claims and are therefore not necessarily subject to the same level of regulation as medical devices (i.e., by government agencies tasked with regulating medical devices). Manufacturers must follow ethical and best practices in marketing tES stimulators, including not misleading users by referencing effects from human trials using devices and protocols not similar to theirs.

The Sensory Abnormality Mediated Partially the Efficacy of Repetitive Transcranial Magnetic Stimulation on Treating Comorbid Sleep Disorder in Autism Spectrum Disorder Children

Sleep disorder emerges as a common comorbidity in children with autism spectrum disorder (ASD), and the interaction between the core symptoms of ASD and its sleep disorder remains unclear. Repetitive transcranial magnetic stimulation (rTMS) was used on the bilateral dorsolateral prefrontal cortex (DLPFC) to investigate the efficacy of rTMS on the core symptoms of ASD and comorbid sleep problems as well as the mediation role of the ASD symptoms between rTMS intervention and sleep improvement. A total of 41 Chinese children with ASD and who met the criteria in the fifth edition of the American Diagnostic and Statistical Manual of Mental Disorders were recruited, and 39 of them (mean age: 9.0 ± 4.4 years old; the male-female ratio was 3.9: 1) completed the study with the stimulating protocol of high frequency on the left DLPFC and low frequency on the right DLPFC. They were all assessed three times (before, at 4 weeks after, and at 8 weeks after the stimulation) by the Children's Sleep Habits Questionnaire (CSHQ), Strengths and Difficulties Questionnaire (SDQ), Childhood Autism Rating Scale, Repetitive Behavior Questionnaire-2, and Short Sensory Profile (SSP). The repeated-measures ANOVA showed that the main effect of "intervention time" of CSHQ (F = 25.103, P < 0.001), SSP (F = 6.345, P = 0.003), and SDQ (F = 9.975, P < 0.001) was statistically significant. By Bayesian mediation analysis, we only found that the total score of SSP mediated the treating efficacy of rTMS on CSHQ (αβ = 5.11 ± 1.51, 95% CI: 2.50-8.41). The percentage of mediation effect in total effect was 37.94%. Our results indicated the treating efficacy of rTMS modulation on bilateral DLPFC for both autistic symptoms and sleep disturbances. The sensory abnormality of ASD mediated the improvement of rTMS on sleep problems of ASD.

Effects of non-invasive neurostimulation on autism spectrum disorder: A systematic review

Non-invasive neurostimulation techniques (NIBS) have shown benefits in psychiatric conditions. While in ASD patients, no guideline has so-far been recommended on these techniques due to a lack of high-quality synthetic evidence. Here, a comprehensive search from database inception onward was conducted in PubMed, EMBASE, and Cochrane library. Sham-controlled studies assessing the effects of NIBS in ASD patients were identified. After screening, twenty-two studies were included. A total of 552 patients were involved, and the sample size ranged from 5 to 78 patients. Although an iteration from exploratory attempts to more strictly designed trials has been seen to evaluate the efficacy of NIBS on ASD, further trials should also be needed to enable the clinicians and researchers to reach any consensus.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021292434], identifier [CRD42021292434].

ADHD: Current Concepts and Treatments in Children and Adolescents

Attention deficit hyperactivity disorder (ADHD) is among the most frequent disorders within child and adolescent psychiatry, with a prevalence of over 5%. Nosological systems, such as the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) and the International Classification of Diseases, editions 10 and 11 (ICD-10/11) continue to define ADHD according to behavioral criteria, based on observation and on informant reports. Despite an overwhelming body of research on ADHD over the last 10 to 20 years, valid neurobiological markers or other objective criteria that may lead to unequivocal diagnostic classification are still lacking. On the contrary, the concept of ADHD seems to have become broader and more heterogeneous. Thus, the diagnosis and treatment of ADHD are still challenging for clinicians, necessitating increased reliance on their expertise and experience. The first part of this review presents an overview of the current definitions of the disorder (DSM-5, ICD-10/11). Furthermore, it discusses more controversial aspects of the construct of ADHD, including the dimensional versus categorical approach, alternative ADHD constructs, and aspects pertaining to epidemiology and prevalence. The second part focuses on comorbidities, on the difficulty of distinguishing between "primary" and "secondary" ADHD for purposes of differential diagnosis, and on clinical diagnostic procedures. In the third and most prominent part, an overview of current neurobiological concepts of ADHD is given, including neuropsychological and neurophysiological researches and summaries of current neuroimaging and genetic studies. Finally, treatment options are reviewed, including a discussion of multimodal, pharmacological, and nonpharmacological interventions and their evidence base.

New Somatic Treatments for Child and Adolescent Depression

PURPOSE OF REVIEW

Depression is a common clinical problem in youth, with prevalence increasing significantly during the adolescent period. Although several evidence-based treatments are currently available for treating depression in adults, only a subset of these have been investigated in a pediatric sample. Unfortunately, even well-established, first-line interventions do not lead to sufficient treatment response for many children and adolescents suffering from depression. However, recent research has been conducted in the area of somatic treatments for youth with depression. This review focuses on current (past three years, including published results and ongoing studies) research on somatic treatments for adolescent depression in the following categories: psychopharmacology, nutraceuticals, interventions implicating motor and sensory systems, and neuromodulation.

FINDINGS

Results from recent randomized, controlled trials testing psychopharmacological options suggest that while antidepressants that have been recently approved for adult patients are safe and tolerable in children and adolescents, none have yet outperformed performed placebo in efficacy. Nutraceuticals, motor-sensory interventions, and neuromodulation techniques, present safe and promising results, but few have been tested against controls to support effectiveness over current treatment options.

SUMMARY

This review of research on pediatric depression treatment from the past 3 years highlights some disappointments (negative results following some of the well-designed clinical trials) and gaps (preliminary studies in need of follow up with robust methodology) but also some promising directions in research of the efficacyof these treatments in a pediatric sample. We offer suggestions for future research including consideration of treatment timing, sequencing, the role of symptom severity in directing treatment selection, the potential value of combined treatments, consideration of how to best account for high placebo response rates, and the incorporation of neurobiological assessments to examine mechanisms and biomarker predictors of treatment response.

An Update on Repetitive Transcranial Magnetic Stimulation for the Treatment of Major Depressive Disorder

Repetitive transcranial magnetic stimulation (rTMS) has emerged as an evidenced-based treatment for major depression that does not respond to standard first-line therapies. The majority of data support the use of high-frequency (10 Hz) treatment delivered to the left dorsolateral prefrontal cortex. Intermittent theta burst stimulation is a new emerging treatment that reduces the time required to deliver treatment and can increase capacity and access to this treatment. This review will comprehensively cover recent advancements in the field of rTMS for depression, including stimulation parameters and targets aimed at enhancing outcomes. In addition, efforts to use modern neuroscience tools to personalize this treatment and optimize outcomes will be reviewed.