Improving Facial Expression Identification in ASD: a Real-time fMRI Neurofeedback Approach
Phase: NA
Conditions: Autism Spectrum Disorder
Sponsor: University of Coimbra

rt-fMRI NF intervention study in ASD 
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IMPROVING FACIAL EXPRESSION 
IDENTIFICATION IN AUTISM 
SPECTRUM DISORDER (ASD): A REAL-
TIME FMRI NEUROFEEDBACK 
APPROACH  
 
PROTOCOL VERSION 14.02.2017 
Sponsor:
University of Coimbra (FMUC) 
 
Sponsor ref:
16482 (UC number) 
 
Funder: 
EU-FP7 
 
Funder ref: 
602186 
Ethics Committee/Board ref: 
Comissão de Ética - FMUC 
Trial registration no:                    NCT02440451                          
 
 
 
 
 
 
This 
protocol 
has 
been authorised by: 
 
 
 
Name 
Role 
Signature 
Date 
Miguel Castelo-Branco
PI for University of Coimbra 
 
 
 

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General Information This protocol describes the rt-fMRI NF intervention in ASD study, and 
provides information about procedures for entering participants. The protocol should not be used as a 
guide, or as an aide-memoire for the care of other patients/participants. Every care has been taken in 
drafting this protocol; however, corrections or amendments may be necessary. These will be circulated 
to the local study team and the most current approved version will be available on the BRAINTRAIN 
extranet.  
 
Compliance This study will adhere to the ICH Harmonised Tripartite Guideline for Good Clinical 
Practice (CPMP/ICH/135/95). It will be conducted in compliance with the protocol and other regulatory 
requirements as appropriate.  
The conducting of clinical trials on medicines for human use is governed by Law n.º 46/2004 of 19 
August that implements Directive 2001/20/EC of the European Parliament and of the Council of 4 April in 
Portuguese legislation. In addition to the above legislation there are a series of guidelines covering various 
matters related to clinical trials which can be found in volume X of Eudralex (see link in PNEC portal below). 
To that end, and as part of the harmonised European system, the conducting of clinical trials in Portuguese 
research centres requires authorisation from INFARMED, I.P. (Autoridade Nacional do Medicamento e 
Produtos de Saúde, I.P.) and a favourable, prior opinion from the CEIC (Clinical Research Ethics 
Committee). 
We will register our trial to http://www.pnec.pt/portal/page/portal/PORTAL_PNEC. PNEC portal is 
a forum that allows all players to work together to transform research in Portugal, through a strategic 
approach that identifies national clinical research opportunities and barriers.  All of the procedures 
described in this project have already been approved by the Ethics Committee of the Faculty of Medicine 
of the University of Coimbra. 
The rt-fMRI NF intervention study in ASD study is funded by the European Commission 7th 
Framework Programme for Research, Technological Development and Demonstration, and is a 
component of Work Package 4. 
 
 

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Sponsor contact details:
 
Title and name
Sónia Pires
Role & responsibilities in relation to trial
Administrative 
Address
ICNAS - Instituto de Ciências Nucleares 
Aplicadas à Saúde, University of Coimbra, 
Azinhaga Santa Comba, Celas 
Postcode
3000- 548 Coimbra
Tel:
+ 351 239 488510
Fax:
+ 351 239 480117
E-mail:
mcbranco@fmed.uc.pt 
 
 
Contact details –Lead Researcher & Co-Investigators  
 
LEAD RESEARCHER 
Title and Name
Miguel Castelo-Branco, MD, PhD
Role & responsibilities in relation to trial
Principal Investigator
Adress
IBILI, Faculty of Medicine, University of 
Coimbra (FMUC), Azinhaga Santa Comba, 
Celas 
Postcode
3000 - 548 Coimbra
Tel :
+ 351 239 480261
Fax :
+ 351 239 480117
E-mail :
mcbranco@fmed.uc.pt
 
CO-INVESTIGATORS 
Title and Name
Guiomar Oliveira, MD, PhD
Role & responsibilities in relation to trial 
Consultant of Pediatrics; Auxiliar Professor of 
Pediatrics – Faculty of Medicine, University of 
Coimbra; 
Head 
of 
Unidade 
de 
Neurodesenvolvimento e Autismo (UNDA) 
and  Director of Centro de Investigação e 
Formação Clínica from Centro Hospitalar e 
Universitário de Coimbra – Hospital Pediátrico 
(CHUC-HP) 
Address :
UNDA-CDC-HP/CHUC Rua 
Doutor Afonso 
Romão 

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Postcode :
3030 Coimbra
Tel :
+351 239488700 ext. 11703
E-mail :
guiomar@chc.min-saude.pt
 
 
Contact Details – Study Team:  
 
Post-doctoral researcher 
 
PhD student 
Bruno Direito, PhD
Carlos Amaral, MSc 
IBILI, Faculty of Medicine, University of Coimbra 
(FMUC), Azinhaga Santa Comba, Celas 
IBILI, Faculty of Medicine, University of Coimbra 
(FMUC), Azinhaga Santa Comba, Celas 
+ 351 239 480261
+ 351 239 480261
+ 351 239 480117
+ 351 239 480117
migueldireito@gmail.com
carlos.amaral@student.fisica.uc.pt
 
Researcher 
 
Researcher 
João Andrade, MSc
João Lima, MSc
IBILI, Faculty of Medicine, University of Coimbra 
(FMUC), Azinhaga Santa Comba, Celas 
IBILI, Faculty of Medicine, University of Coimbra 
(FMUC), Azinhaga Santa Comba, Celas 
+ 351 239 480261
+ 351 239 480261
+ 351 239 480117
+ 351 239 480117
joao.andrade@uc.pt
joao.lima@uc.pt
 
Post-doctoral researcher 
 
PhD student 
José Cecílio, PhD
Marco Simões, MSc
IBILI, Faculty of Medicine, University of Coimbra 
(FMUC), Azinhaga Santa Comba, Celas 
IBILI, Faculty of Medicine, University of Coimbra 
(FMUC), Azinhaga Santa Comba, Celas 
+ 351 239 480261
+ 351 239 480261
+ 351 239 480117
+ 351 239 480117
josemcecilio@gmail.com
msimoes@dei.uc.pt

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PhD student 
 
Statistician 
Susana Mouga, MSc 
Bárbara Baía, PhD 
IBILI, Faculty of Medicine, University of Coimbra 
(FMUC), Azinhaga Santa Comba, Celas 
IBILI, Faculty of Medicine, University of Coimbra 
(FMUC), Azinhaga Santa Comba, Celas 
3000- 548 Coimbra
3000- 548 Coimbra
+ 351 239 480261
+ 351 239 480261
+ 351 239 480117
+ 351 239 480117
susana.mouga@fmed.uc.pt
regadas.correia@gmail.com 
 
 
Clinical queries: 
 
 
 
Serious Adverse Events: 
 
 
 
 
 
 
 
 

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Table of Contents 
 
1 
Amendment History....................................................................................................................... 11 
2 
Synopsis......................................................................................................................................... 13 
3 
Study summary & schema.............................................................................................................. 14 
3.1 
Study schema ......................................................................................................................... 14 
3.2 
Participant flow diagram ........................................................................................................ 14 
3.3 
Study summary ...................................................................................................................... 14 
4 
Introduction .................................................................................................................................. 15 
4.1 
Background ............................................................................................................................ 15 
4.2 
Rationale for current study .................................................................................................... 16 
5 
Study objective(s) .......................................................................................................................... 17 
5.1 
Primary objective(s) ............................................................................................................... 17 
5.2 
Secondary objectives ............................................................................................................. 17 
6 
Trial/study design .......................................................................................................................... 18 
7 
Participant selection ...................................................................................................................... 18 
7.1 
Inclusion criteria .................................................................................................................... 18 
7.2 
Exclusion criteria .................................................................................................................... 19 
8 
Recruitment ................................................................................................................................... 19 
8.1 
Number of participants .......................................................................................................... 19 
8.2 
Recruitment process .............................................................................................................. 19 
8.3 
Informed consent ................................................................................................................... 19 
8.4 
Screening logs ........................................................................................................................ 19 
9 
Withdrawal & loss to follow-up ...................................................................................................... 20 
10 
Intervention ............................................................................................................................... 20 
10.1 
fMRI ....................................................................................................................................... 20 
10.2 
Possible undesirable effects ................................................................................................... 20 
10.3 
Intervention arms .................................................................................................................. 21 
10.4 
Brain area/s of interest .......................................................................................................... 21 
10.5 
Adherence ............................................................................................................................. 21 

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11 
Outcome measures .................................................................................................................... 22 
11.1 
Primary outcome measure ..................................................................................................... 22 
11.2 
Secondary outcome measures ............................................................................................... 22 
12 
Study procedures ....................................................................................................................... 26 
12.1 
Data collection ....................................................................................................................... 26 
12.2 
Screening ............................................................................................................................... 26 
12.3 
Pre-test .................................................................................................................................. 26 
12.4 
Post-test ................................................................................................................................ 26 
12.5 
Follow-up ............................................................................................................................... 26 
12.6 
Samples & storage ................................................................................................................. 26 
12.7 
Facilities & equipment ........................................................................................................... 27 
12.8 
Incidental findings .................................................................................................................. 27 
13 
Statistical considerations ........................................................................................................... 27 
13.1 
Randomisation ....................................................................................................................... 27 
13.2 
Sample size ............................................................................................................................ 27 
13.3 
Missing, unused & spurious data ............................................................................................ 28 
13.4 
Procedures for reporting deviation(s) from the original SAP ................................................... 28 
13.5 
Termination of the study ........................................................................................................ 28 
14 
Adverse Events .......................................................................................................................... 28 
14.1 
Definitions ............................................................................................................................. 28 
14.2 
Causality ................................................................................................................................ 29 
14.3 
Expectedness ......................................................................................................................... 30 
14.4 
Reporting procedures ............................................................................................................ 30 
14.4.1 
Events exempt from reporting (non-serious AEs) ............................................................ 30 
14.5 
Urgent Safety Measures (USMs) ............................................................................................. 31 
15 
Analysis ...................................................................................................................................... 31 
15.1 
Main analysis ......................................................................................................................... 31 
15.1.1 
Sub-group & interim analysis .......................................................................................... 31 
16 
Data storage & retention ........................................................................................................... 31 
17 
Study closure ............................................................................................................................. 32 
18 
Regulatory issues ....................................................................................................................... 32 

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18.1 
Ethical and research governance approval ............................................................................. 32 
18.2 
Consent ................................................................................................................................. 32 
18.3 
Confidentiality ....................................................................................................................... 32 
18.4 
Indemnity .............................................................................................................................. 32 
18.5 
Trial sponsorship .................................................................................................................... 33 
18.6 
Funding .................................................................................................................................. 33 
18.7 
Audits & inspections .............................................................................................................. 33 
19 
Study/trial management ............................................................................................................ 33 
20 
Data monitoring & quality assurance ......................................................................................... 33 
20.1 
T/SSC (Trial/Study Steering Committee) ................................................................................. 33 
20.2 
IDMC (Independent Data Monitoring Committee) .................................................................. 34 
21 
Publication policy ....................................................................................................................... 34 
22 
Milestones ................................................................................................................................. 34 
23 
References ................................................................................................................................. 35 
24 
Appendices ................................................................................................................................ 38 
 
 
 
 
 
 
 
 
 
 

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Glossary of abbreviations 
AE
Adverse Event
ASD 
Autism Spectrum Disorder 
ATEC
Autism Treatment Evaluation Checklist
BDI
Beck Depression Inventory
CRF
Case Report Form
DMC
Data Monitoring Committee
EU
European Union
FEEST
Facial Expressions of Emotion – Stimuli and Tests 
fMRI
Functional Magnetic Resonance Imaging
FP-7
7th Framework Programme for Research, Technological Development & 
Demonstration 
GCP
Good Clinical Practice
HADS
Hospital Anxiety and Depression Scale
ICH
International Conference on Harmonization
ISRCTN
International Standard Randomised Controlled Trial Number
PIS
Patient Information Sheet
POMS
Profile of Mood States questionnaire
RCT
Randomised Controlled Trial
SAE
Serious Adverse Event
SEWTU
South East Wales Trials Unit
SOP
Standard Operating Procedure
STAIC
State/Trait Anxiety Inventory for Children
TCQ
Thought Control Questionnaire
TCAQ
Thought Control Ability Questionnaire
TMF
Trial Master File

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TMG
Trial Management Group
TSC
Trial Steering Committee
USM
Urgent Safety Measure
VABS
Vineland Adaptive Behaviour Scales 
WAIS-III
Wechsler Adult Intelligence Scale 
 
 
 

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1 
Amendment History 
Amendment 
No. 
Protocol 
version 
no. 
Date 
issued 
Author(s)  
of changes 
Details of changes made 
 
V 1.0 
 
 
 
 
V 1.2 
14-02-
2017 
Susana 
Mouga, 
Bruno Direito, 
Bárbara Baía 
1. Study Team: Bárbara Baía was 
included as the team statistician. 
2. Figure presented in Section 3.2 
Participant flow diagram was 
updated. Follow-up was included 
in the figure. 
3. Text in Section 4.2 Rationale for 
current 
study 
was 
edited. 
Clarifications on the design and 
statistical plan were included. 
4. Figure presented in Section 6 
Trial/study design was updated. 
Follow-up was included in the 
figure. 
5. Text in Section 10.3 Intervention 
arms was edited. Clarifications on 
the design and sessions schedule 
were included. 
6. Text in Section 12.5 Follow-up was 
edited. Clarifications on the long-
term analysis were included. 
7. Text in Section 13.2 Sample size 
was edited. Clarifications on the 
statistical test were included. 
8. Text in Section 15.1 Main analysis 
was edited. Clarifications on the 
statistical procedures that will be 
used in the main analysis were 
included. 
 

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2 
Synopsis 
 
Short title
rt-fMRI NF intervention study in ASD
Acronym
NF-ASD
Internal ref. no.
IBILI – VB - 2015 – 02
Trial/study design
SINGLE ARM WITHIN – SUBJECT “BEFORE-AFTER” DESIGN. 
Trial/study 
participants 
ASD (experimental)
Planned sample 
size 
15 (plus 3 in case of drop outs)
Follow-up duration
6 months after last session
Planned 
trial/study period 
2 months (5 sessions, 4 sessions in first month and 1 one month 
later) 
Primary objective
To improve social cognition in terms of facial emotional 
recognition 
Secondary 
objectives 
To generalize improvements to other social and cognitive
domains. 
Primary endpoint
Increase the score of successful emotion recognition in the 
Hexagon test 
Secondary 
endpoints 
Improve standard neuropsychological scores in clinical scales 
(Vineland, ATEC) 
Interventions
rt-fMRI NF 
 
 
 

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3 
Study summary & schema 
3.1 
Study schema 
 
3.2 
Participant flow diagram 
 
3.3 
Study summary 
Clinical research has demonstrated that ASD children have deficits in the identification and 
interpretation of the emotional and mental state of others (Baron-Cohen 2001). An important skill to this 
end (impaired in ASD patients), is to appropriately recognize and discriminate emotional expressions. 
The main brain regions involved in face processing are the inferior occipital gyri, lateral portion of 
the fusiform gyrus (especially a region deemed the fusiform face area or FFA), and posterior superior 
temporal sulcus (pSTS) (Haxby et al. 2000). Superior temporal sulcus (STS) plays a key role on several basic 
aspects in social information processing, and deficits in ASD have been found associated to this region. 
The purpose of the study is to determine the effect of neurofeedback considering a social cognition 
brain region (i.e. pSTS) on the identification of facial expressions in ASD patients. The intervention 
comprises five neurofeedback sessions spread over two months. The first four sessions are weekly, and 
the last session performed one month later. In each session, the subjects are asked to imagine different 
facial expressions and their brain activity (i.e. BOLD activation in the pSTS region) is interpreted and used 
to estimate a feedback signal. We hypothesise that the training induces up-regulation of the target region 
(pSTS) that is highly related to clinical symptoms, as recognition of emotional states. This will improve 

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these specific clinical symptoms as can be measured by Facial Expression of Emotion: Stimuli and Tests 
(FEEST) - The Emotion Hexagon. Improvements the results in Autism Treatment Evaluation Checklist 
(ATEC) [Sociability and Cognitive Awareness Subtests] and in Vineland Adaptive Behaviour Scale (VABS) 
[Socialization and Daily Living Skills Domains] are also expected. 
 
4 
Introduction 
4.1 
Background 
The technological advances raised from the use of multivariate supervised learning methods and 
from real-time functional magnetic resonance imaging (rt-fMRI) allows the development of new 
approaches capable of decoding a subject's brain state from functional magnetic resonance (fMRI) images 
(Formisano et al., 2008). The decoded brain states can be used as a control signal for a brain computer 
interface (BCI) or to provide neurofeedback (NF) to the subject (LaConte, 2011). 
There is accumulating evidence from rtfMRI neurofeedback experiments that local brain activity 
measured by the blood oxygenation level dependent (BOLD) response can be specifically regulated 
(Weiskopf, 2012). Different brain regions have been identified as the target of NF studies, such as the 
somatosensory cortex (Bray et al., 2007; deCharms et al., 2004; Yoo et al., 2004), motor areas (LaConte et 
al., 2007; Sitaram et al., 2012; Weiskopf et al., 2004), amygdala (Johnston et al., 2010; Posse et al., 2003), 
anterior cingulate cortex (deCharms et al., 2005; Hamilton et al., 2011; Weiskopf et al., 2003) and visual 
areas (Scharnowski et al., 2012). 
The brain activity associated with one particular state can be distinguished from alternate 
possibilities. The effectiveness of this identification is a key factor to determine whether the conscious 
and unconscious perceptual or cognitive states of an individual can be decoded. The ideal case of such 
separation is given when different cognitive states are encoded in spatially distinct locations of the brain 
resolved with the limited resolution of the fMRI (Haynes and Rees, 2006).  
 
Emotional expression recognition 
The identification of emotional and mental states of others is a major problem in individuals with 
ASD (Baron-Cohen, 2001). A fundamental skill to this process is the ability to recognize and discriminate 
emotional expressions. This skill is present from at least 10 weeks of age in typically developing infants 
(Haviland and Lelwica (1987) showed that 10 weeks old infants respond to three different facial 
expressions) and it continues to develop across childhood (Herba et al., 2006). ASD individuals show delays 
in the development of this ability (Baron-Cohen et al., 2001; Golan et al., 2008).  
 

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The main brain regions involved in face processing include the inferior occipital gyri, lateral portion 
of the fusiform gyrus (especially a region deemed the fusiform face area, or FFA), and pSTS (Haxby et al. 
2000). 
STS has been widely studied regarding social cognition processing and in particular the 
analysis of visual social cues (social perception) (Allison et al., 2000). Previous studies have 
concluded that STS plays a key role on several basic aspects in social information processing 
(biological movement, eye gaze) and furthermore, it was found that ASD subjects are affected 
by a decrease of gray matter in STS (Zilbovicius et al, 2013). 
Some studies have identified differences in the facial processing of emotions in ASD 
subjects when compared with typically developing peers. Dapretto et al., 2006 found 
functional abnormalities in the frontal gyrus, which suggested a mirror neuron system deficit. 
It is common to find in the literature decreased activation in the fusiform gyrus in ASD 
individuals, when categorizing facial expressions of emotion (Hubl et al. 2003; Pierce et al. 
2001; Schultz et al. 2000; Wang et al., 2004). However, it is not a universal finding 
(Bookheimer et al. 2008), especially when familiar faces are used as stimuli (Pierce and 
Redcay 2008).  
Haxby and colleagues (2000) showed that the fusiform regions of the brain are more 
involved in processing constant characteristics of the faces, like identity, whereas the pSTS 
region is more involved in processing of dynamic characteristics, like eye gaze or facial 
expression. 
A study from Ashwin and colleagues (2007) looked for responses to neutral, scrambled 
and fearful faces (with high and low intensity) and concluded that ASD individuals did not 
modulate FFA, medial pre-frontal cortex, amygdala, or STS in response to the different 
conditions, contrasting with the control group. 
A NF study based on the up-regulation of emotional areas (including STS) was 
performed and showed that in the end participants were able to gain control over their brain 
activity. However, the training has been probably too short and longer NF sessions should be 
carried out (Johnston et al, 2011). 
4.2 
Rationale for current study 
This study aims to demonstrate that fMRI neurofeedback training improves the ability to identify 
emotional facial expressions (and overall social behaviour) in subjects with ASD. 
The intervention setup provides structured presentation of emotional facial expressions and the 
associated tools for mental imagery. We hypothesize that the accomplishment of the proposed 
competence training improves the subject’s ability to comprehend facial expressions, identify emotions 
and be able to correctly express them. 

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To evaluate the improvements, we will use the results of the Facial Expression of Emotion: Stimuli 
and Tests (FEEST) - The Emotion Hexagon test. We expect that ASD subjects will be able to improve the 
number of expressions correctly recognized. 
Considering the prospective, single Arm, longitudinal design proposed, with alpha 0.05, power of 
0.8 and standardized effect of 0.82 we would need 14 subjects. We will consider three additional subjects 
to account for drop-offs. The sample size calculations were performed under the assumption that the 
distribution of the mean differences is normal and based on a paired t-test (2-tailed). However, without 
the normality assumption, we would need 15 subjects, considering a non-parametric test. 
 To determine these values we used the G*Power tool (Faul, Erdfelder, Lang, & Buchner, 2007). 
Structure: (1) initial eligibility screening, (2) pre-intervention, (3) intervention process, (4) post-
intervention, and (5) follow-up. 
 
5 
Study objective(s) 
 
5.1 
Primary objective(s) 
Improving the appropriate identification of emotional facial expressions, as measured by the 
Facial Expression of Emotion: Stimuli and Tests (FEEST) - The Emotion Hexagon test. 
 
5.2 
Secondary objectives 
Generalization of learned skills to general aspects in social cognition. 
 
 

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6 
Trial/study design 
 
 
Allocation: not applicable 
Endpoint Classification: Efficacy Study 
Intervention Model: Single arm 
Primary Purpose: Basic Science and clinical feasibility study 
Participants: 15 ASD subjects (plus 3 in case of drop outs) 
 
7 
Participant selection  
The eligible patients for the study should be high functioning ASD adolescents and adults. These 
participants should also meet all the following inclusion criteria and none of the exclusion criteria. All 
queries about patient eligibility should be directed to Susana Mouga before registration. 
7.1 
Inclusion criteria 
 
Positive diagnostic results for ASD in: 
o Autism Diagnostic Interview-Revised; 
o Autism Diagnostic Observation Schedule;  

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o The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) 
criteria. 
 
7.2 
Exclusion criteria 
 
Global Intelligence Quotient < 80 
 
Associated medical condition such as epilepsy, neurocutaneous or other genetic 
syndromes, or other usual comorbidity in ASD samples 
 
8 
Recruitment  
8.1 
Number of participants  
A total of 15 (plus 3 in case of drop outs) participants will be recruited at a rate of two for each 
three weeks (see sample size calculation below). 
 
8.2 
Recruitment process 
Participants will be recruited from the National Clinical Program for ASD at University of Coimbra. 
The Lead Researcher is responsible for contacting the participants. 
 
8.3 
Informed consent 
Informed Consent form can be found attached in the appendices. This Informed Consent form must 
be signed by each participant/legal representative before the beginning of the study.  
 
8.4 
Screening logs 
The data related to screening logs (paper format) will be kept in a secured room only accessible by 
BRAINTRAIN researchers. Additionally, data required to support analysis of the study will be entered and 
stored in an MS SQL Server database hosted on servers at Cardiff University. The hosting server is on a 
locked, secure machine room at Cardiff University. 
The database will be backed up daily and access to the database will be via secure logon (username 
and password) and restricted to named study personnel only, as detailed in the study’s PRA log. Each 
study will only see data and actions relating to their own study. 

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9 
Withdrawal & loss to follow-up 
Participants have the right to withdraw consent for participation in any aspect of the rt-fMRI NF 
intervention in ASD study at any time. The participant’s care will not be affected at any time by declining 
to participate or withdrawing from the study. 
If a participant initially consents but subsequently withdraws from the study, clear distinction must 
be made as to what aspect of the study the participant is withdrawing from. These aspects could be: 
1. Withdrawal from study intervention  
2. Withdrawal from study follow-up  
3. Withdrawal from entire study and does not want data to be used. 
A patient may withdraw or be withdrawn from the intervention for the following reasons: 
 
Withdrawal of consent for intervention by the participant 
 
Any alteration in the participants condition or circumstances which justifies the 
discontinuation of the intervention in the Investigators’ opinion  
In all instances participants who consent and subsequently withdraw should complete a 
withdrawal form or the withdrawal form should be completed on the participant’s behalf by 
the researcher based on information provided by the participant.  
 
10 
Intervention 
10.1 fMRI 
During the scan radiographers will be able to see and monitor participants from the control room 
for the duration of the scan. Participants will be given a call button and can communicate through an 
intercom. The scan can be stopped at any time, should participants’ request this or radiographers become 
concerned about a participant’s health. 
 
10.2 Possible undesirable effects 
The known undesirable effects may include: 
 
The scanner may produce a loud noise when in use. Ear defenders or earplugs will be 
provided to help reduce this 

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 
Some participants feel claustrophobic during the scan 
 
The scan is not painful but requires participants to remain motionless on a table for up to 
45 minutes 
 
The scan may reveal incidental findings (see section 12.8) 
 
10.3 Intervention arms 
Experimental: Neurofeedback intervention 
This group will undergo five sessions of neurofeedback intervention in the fMRI scanner. Each 
subject will also undergo neuropsychological evaluations before the first neurofeedback session, after the 
last neurofeedback session and on follow-up. The first four sessions are weekly while the last one is one 
month later. The intervention will take a total of two months. 
 
10.4 Brain area/s of interest 
Posterior Superior Temporal Sulcus  
Rationale 
pSTS has been associated with social perception processing/social conceptual knowledge (Moll et 
al., 2014; Saitovitch et al., 2012). In this study, we aim to determine if the training / modulation of the 
networks that integrate this region may influence an improvement /enhances the social behaviour / facial 
expression interpretation. 
 
10.5 Adherence 
Adherence is defined as attending all five NF sessions. 
After the enrolment, the participant will be given a schedule with the sessions plan. Additionally, 
the participant or caregiver will be reminded of each session by telephone-call one week earlier and by 
message the day before. 
On the basis of following the study protocol, follow-up plan should depend on specific situation of 
participants such as avoiding the holiday or the inconvenient day. When the intervention is over, 
researchers should remind patients of the next appointment time. For eventual absent participants, 
researchers should do telephone interviews in time, ask the reason and try to reschedule. 
 

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11 
Outcome measures 
11.1 Primary outcome measure 
The results in the Facial Expression of Emotion: Stimuli and Tests (FEEST) - The Emotion Hexagon 
test will be the primary outcome measure. The group will be evaluated in the pre and post evaluation 
time with this test. The Emotion Hexagon test uses stimuli of graded difficulty, created using computer 
image manipulation techniques (morphing is used to modify photographs from the Ekman and Friesen 
(1976) series, creating examples that lie close to or more distant from the prototype expression). The 120 
test trials with unambiguous stimuli (4 pictures for each of the 6 emotions across the 5 test blocks) can be 
used to derive an overall (total) score out of a possible maximum of 120 expressions correctly recognized. 
11.2 Secondary outcome measures 
Secondary outcomes comprise the core measures detailed in Table 1 below. 
 
The results in Autism Treatment Evaluation Checklist (ATEC) [Sociability and Cognitive 
Awareness Subtests] will be one of the secondary outcome measures. The group will be 
evaluated in the pre and post evaluation time with this test. 
 
The results in Vineland Adaptive Behaviour Scale (VABS) [Socialization and Daily Living Skills 
Domains] will be one of the secondary outcome measures. The group will be evaluated in 
the pre and post evaluation time with this test. 
 
Table 1. BRAINTRAIN core outcomes 
Measure 
Outcome(s) 
Description 
Timepoint 
Demographic 
questionnaire 
Age, gender, 
education, SES
  
Baseline 
Thought control 
questionnaire 
(TCQ)(Wells & 
Davies, 1994) 
Though control 
(distraction, 
punishment, 
worry; re-
appraisal; 
social control) 
30-item measure to assess 
effectiveness of strategies used 
for the control of 
unpleasant/unwanted thoughts 
Baseline 

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Thought control 
ability 
questionnaire 
(TCAQ)(Luciano 
et al., 2005) 
Thought 
control 
25-item measure of individual 
differences in perceived ability to 
control unwanted & intrusive 
thoughts 
Baseline 
Wechsler Adult 
Intelligence 
Scale (WAIS-
III)(Wechsler, 
1997) 
IQ 
Global intelligence/IQ measure 
Baseline 
Profile of Mood 
States 
(POMS)(Heuche
rt and McNair, 
2012) 
Anger; 
confusion; 
depression; 
fatigue; 
tension and 
vigour 
  
Pre-post 
assessment 
(each 
session) 
Hospital 
Anxiety & 
Depression 
Scale 
(HADS)(Zigmon
d and Snaith, 
1983) 
Anxiety; 
depression 
24-item scale (7 depression & 7 
anxiety items) 
Pre-post 
assessment 
(across 
intervention)
Beck 
Depression 
Inventory (BDI-
II)(Beck et al., 
1996) 
Depression 
21-item measure of clinical 
depression 
Pre-post 
assessment 
(across 
intervention)

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Autism 
Treatment 
Evaluation 
Checklist 
(ATEC) 
(Rimland and 
Edelson, 1999) 
Autism Traits 
77-items: 
speech/language/communication 
(14 items); sociability (20 
items); sensory/cognitive 
awareness (18 items); 
health/physical/behaviour (25 
items) 
Pre-post 
assessment 
(across 
intervention)
Vineland 
Adaptive 
Behaviour 
Scales (VABS) 
(Sparrow et al., 
1984) 
Adaptive 
Behaviour 
297 items measure of adaptive 
behaviour 
Three main domains: 
Communication (COM), Daily 
Living Skills (DLS) and 
Socialization (SOC) and total 
score, the Adaptive Behaviour 
Composite (ABC) 
Pre-post 
assessment 
(across 
intervention)
Facial 
Expressions of 
Emotion – 
Stimuli and 
Tests - FEEST 
(The Emotion 
Hexagon test) 
(Young et al, 
2002) 
Emotion 
recognition 
30 computer-manipulated images 
of faces (yielding a possible 
maximum of 120 expressions 
correctly recognized) from the 
Ekman and Friesen series to test 
recognition of basic emotions 
(anger, disgust, fear, happiness, 
sadness, and surprise) 
Pre-post 
assessment 
(across 
intervention)
Debriefing 
interview 
questionnaire 
  
Covers: strategies; general 
experience of the process; 
adverse effects;  
Post-
assessment 
(ideally each 
session) 
  

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12 
Study procedures 
 
12.1 Data collection 
All data collected from the MRI scanner (training and testing steps) will be stored on the MRI setup. 
After each session, data will be copied onto a hard-drive for posterior analysis. 
The tests related to the neuropsychological evaluation will be collected on paper at site and entered 
manually online into the information system. 
 
12.2 Screening 
Not applicable. 
 
12.3 Pre-test 
Participants will undergo an initial diagnostic and neuropsychological evaluation, followed by an a 
priori assessment of the outcome measures (i.e., Facial Expression of Emotion: Stimuli and Tests - FEEST: 
The Emotion Hexagon, Autism Treatment Evaluation Checklist (ATEC) [Sociability and Cognitive Awareness 
Subtests], Vineland Adaptive Behaviour Scale (VABS) [Socialization and Daily Living Skills Domains]), for 
establishing baseline metrics. 
 
12.4 Post-test 
Once concluded the intervention, the group perform the a posteriori evaluation, to assess the 
hypothesized improvements on the measures, as compared to pre-test assessment. 
 
12.5 Follow-up 
6 months for follow-up of neuropsychological performance (Hexagon, etc) and to assess the 
hypothesized improvements on the measures (long-term). 
12.6 Samples & storage 
Not applicable. 
 

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12.7 Facilities & equipment 
fMRI scanning will be performed on a 3T Siemens Magnetom TimTrio scanner, at the Portuguese 
Brain Imaging Network, using a 12-channel head coil. For each participant, scanning will include the 
acquisition of blood oxygenation level-dependent (BOLD) contrast echo planar imaging (EPI) fMRI runs. 
 
12.8 Incidental findings 
At the time of consent, participants will be advised that scans will be performed using a research 
protocol and as such are different from diagnostic MRI and do not replace usual medical care. The scans 
may however reveal a suspected abnormality and the PIS and consent form should explain the possibility 
of incidental findings, and the procedure to be followed should this occur. Participants must explicitly 
consent to secondary review of their scans by a neurologist/radiologist should this be indicated, and to 
the research team contacting their doctor to advise further follow-up if necessary (or to direct referral for 
follow-up, depending on local procedures). 
Should an MRI reveal a suspected abnormality, the following procedure will be followed: 
 
To avoid distress to participants arising from false alarms, staff must not disclose their 
concerns to the participant  
 
The authorised person must report their concerns to a neurologist/radiologist, supplying a 
digital copy of the image and a description of the cause for concern 
 
The neurologist/radiologist will review the scan and associated report and decide whether 
further follow-up is necessary 
 
In the event further follow-up is required, the Lead Researcher will be responsible for 
ensuring the participant’s named doctor is contacted to arrange further follow-up. 
13 
Statistical considerations 
13.1 Randomisation 
Not Applicable 
 
13.2 Sample size 
In the age group 20–30 Mean is known to be 109.00 (±SD=8.75) (out of 120). A previous study by 
Philip et al. (2010: Philip, RCM, Whalley, H, Stanfield, AC, Sprengelmeyer, R, Santos, IM, Young, AW, 
Atkinson, AP, Calder, AJ, Johnstone, EC, Lawrie, SM & Hall, J 2010) showed that in ASD deficits are present 
in identifying ‘anger’, ‘sadness’ and ‘fear’. 

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In this study, the control group showed mean accuracy of 92.43% (±SD=7.57). The autism spectrum 
disorder (ASD) group was subdivided according to the Autism Diagnostic Observational Schedule (ADOS) 
score. The mean accuracy in the ADOS negative group was 81.33% (±SD 13.53) and in the ADOS positive 
group 76.45% (±SD 14.00).  
Assuming the later values, and conservatively expecting a normalization from 81.33% to 92.43% in 
a within subject design with a standardized effect size of 0.82, the required sample size at an alpha level 
of 0.05 and power of 0.8, would be 14 subjects. The sample size calculations were performed under the 
assumption that the distribution of the mean differences is normal and based on a paired t-test (2 tailed). 
However, without the normality assumption, we would need 15 subjects, considering a non-parametric 
test. To determine these values we used the G*Power tool (Faul, Erdfelder, Lang, & Buchner, 2007). 
13.3 Missing, unused & spurious data 
Detail provided in the Statistical Analysis Plan (SAP). 
 
13.4 Procedures for reporting deviation(s) from the original SAP 
These will be submitted as substantial amendments where applicable and recorded in subsequent 
versions of the protocol and SAP. 
 
13.5 Termination of the study 
Reasons for early termination of the study include unexpected unacceptable side effects.  
 
14 
Adverse Events 
 
14.1 Definitions 
Adverse Event (AE): Any untoward medical occurrence in a participant which does not necessarily 
have a causal relationship with this treatment. An AE can therefore be any unfavourable and unintended 
sign (including abnormal laboratory finding), symptom, or disease.  
 
Serious Adverse Event (SAE): Any adverse event that:  
 
• Results in death  

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• Is life-threatening*  
• Required hospitalisation or prolongation of existing hospitalisation**  
• Results in persistent or significant disability or incapacity  
• Consists of a congenital anomaly or birth defect  
• Other medically important condition ***  
* Note: The term “life-threatening” in the definition of serious refers to an event in which the 
participant was at risk of death at the time of the event; it does not refer to an event which hypothetically 
might have caused death if it were more severe.  
** Note: Hospitalisation is defined as an inpatient admission, regardless of the length of stay, even 
if the hospitalisation is a precautionary measure, for continued observation. Pre-planned hospitalisation 
e.g. for pre-existing conditions which have not worsened or elective procedures does not constitute an 
adverse event.  
*** Note: other events that may not result in death are not life-threatening, or do not require 
hospitalisation may be considered as a serious adverse event when, based upon appropriate medical 
judgement, the event may jeopardise the participant and may require medical or surgical intervention to 
prevent one of the outcomes listed above.  
14.2 Causality 
The assignment of causality should be made by the Investigator responsible for the care of the 
participant.  
 
Table 2. Causality 
Relationship
Description
Unrelated 
There is no evidence of any causal relationship with the study or 
intervention.  
Unlikely 
There is little evidence to suggest there is a casual relationship (e.g. 
the event did not occur within a reasonable time after intervention) 
with the study or intervention. There is another reasonable 
explanation for the event (e.g. the participant’s clinical condition, 
other treatment). 
Possible 
There is some evidence to suggest a causal relationship with the study 
or intervention (e.g. because the event occurs within a reasonable 
time after intervention). However, the influence of other factors may 

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have contributed to the event (e.g. the participant’s clinical condition, 
other treatments). 
Probable 
There is evidence to suggest a causal relationship and the influence of 
other factors is unlikely. 
Definite 
There is clear evidence to suggest a causal relationship and other 
possible contributing factors can be ruled out. 
Not 
assessable 
There is insufficient or incomplete evidence to make a judgement of 
the causal relationship. 
 
 
14.3 Expectedness 
The assessment of whether or not an SAE is an expected consequence of receiving the intervention 
will be provided by the Lead Researcher.  
Depending on the nature of the event, the reporting procedures outlined in this protocol should be 
followed. Any queries concerning adverse event reporting should be directed to Miguel Castelo Branco - 
Chief investigator/Lead researcher.  
 
14.4 Reporting procedures 
14.4.1 
Events exempt from reporting (non-serious AEs) 
All such events, whether expected or not, should be recorded on the relevant case report form. 
An SAE form should be completed for all SAEs within 24 hours. Events exempt from SAE reporting 
are set out in the Table below and information relating to them should instead be captured on the relevant 
CRF. 
 
Table 2: Adverse Events exempt from reporting 
Adverse Event 
Information 
Nauseas 
Participants may suffer from nauseas during the fMRI acquisition. 
Discomfort 
Patients suffer from claustrophobia may suffer some discomfort due to the 
scanner dimensions. 

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Additional information should be sent within 5 days if the event has not resolved at the time of 
reporting. All events should be followed up through to resolution.  
In the case of serious, unexpected and related adverse events, the main procedures to be followed 
are specified in the informed consent form. This document can be found attached in the appendices. 
 
14.5 Urgent Safety Measures (USMs) 
An urgent safety measure is an immediate change in a trial procedure or temporary halt to a trial 
procedure, put in place prior to approval in order to protect participants from any immediate hazard to 
health and safety following new safety information (SAE or other information received from an external 
source). The Lead Researcher may carry out USMs to protect participants from immediate harm.   
 
15 
Analysis 
15.1 Main analysis 
Initially will conduct an exploratory data analysis using graphical techniques (box and scatter 
plots) and quantitative analysis (statistical measures and frequency table) in order to characterize the 
sample, detect possible extreme outliers and measurement error. 
To detect differences between the three time points of neuropsychological evaluation (session 1, 
session 5 and follow-up) will perform the Repeated-measures ANOVA. To identify the difference between 
each evaluation, the paired t tests will perform (note: considering a normal distribution). 
However, without the normality assumption, we will consider a non-parametric test. 
Further details will be found in the SAP. 
15.1.1 
  Sub-group & interim analysis 
Not applicable. 
 
16 
Data storage & retention 
Data collected on paper will be kept in a secured room only accessible by BRAINTRAIN researchers, 
for a minimum period of 5 years after publication. 

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Data required to support analysis of the study will be entered and stored in an MS SQL Server 
database hosted on servers in a secure machine room at Cardiff University. This room is locked and entry 
is via a swipe card system. 
The database will be backed up daily and access to the database will be via secure logon (username 
and password) and restricted to named study personnel only, as detailed in the study’s PRA log. 
 
17 
Study closure 
The trial will end up to 74 weeks after its start (including follow-up). 
 
18 
Regulatory issues 
18.1 Ethical and research governance approval 
The study will be conducted in accordance with the recommendations for physicians involved in 
research on human participants adopted by the 18th World Medical Assembly, Helsinki 1964 and later 
revisions. 
Ethical approval for this study will be given by the Ethical Committee of the Faculty of Medicine of 
University of Coimbra. Research governance approval will be granted by CEIC and will be sought after 
document approval. 
18.2 Consent 
Consent will only be considered informed following provision of adequate participant information 
(see attached information sheet and consent form). Participants will be informed that they are free to 
withdraw at any time and that this will not impact on current or future care. 
 
18.3 Confidentiality 
Data Confidentiality is assured as stated in the Informed Consent form, according with the 
Portuguese data protection regulations as per the EU directive. This document can be found attached in 
the appendices. 
 
18.4 Indemnity 
Although not expected due to participation in this study, if the subject suffers any injury as a result 
of any study procedures, performed according to the protocol, the subject will be reimbursed for medical 

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expenses necessary to treat them. All procedures are reviewed by staff and all incidents reported to 
appropriate persons and / or entities. 
 
18.5 Trial sponsorship 
Faculty of Medicine of University of Coimbra. 
 
18.6 Funding 
The Improving facial expression identification in ASD: a real-time fMRI neurofeedback approach 
study is funded by the European Commission 7th Framework Programme for Research, Technological 
Development and Demonstration. 
 
18.7 Audits & inspections 
The study may be participant to inspection and audit by CEIC /Infarmed. 
 
19 
Study/trial management 
LBIM (Laboratory of Biostatistics and Medical Informatics of the Faculty of Medicine of University 
of Coimbra) will manage the trial. 
We will keep, weekly project team meetings, monthly study management group meetings. These 
meetings will be attended by researchers directly involved in running the study. 
 
20 
Data monitoring & quality assurance 
 
20.1 T/SSC (Trial/Study Steering Committee) 
The TSC will be established centrally for the BRAINTRAIN consortium and include external clinical 
and methodological experts, at least one service user and an independent statistician. Members will be 
required to sign up to the remit and conditions as set out in the TSC Charter. 
 

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20.2 IDMC (Independent Data Monitoring Committee) 
The nature of this study makes it unlikely that a separate Data Monitoring Committee (DMC) will 
be required; however, this will be discussed with the TSC at their first meeting and a DMC will be set up if 
deemed necessary. Members will be required to sign up to the remit and conditions as set out in the DMC 
Charter. 
 
21 
Publication policy 
 
The Publication Policy is detailed in <<document title>> and can be found on the 
BRAINTRAIN extranet <<file location>>. 
 
22 
Milestones 
 
Table 3. Milestones 
 
 
 
TASK 
START 
DURATION
Months
  
  
  
1 
2 
3 
4 
5 
6 
7 
8 
9 
10
11
12
13
14
15
16
17
18
19
Recruiting 
1 
5 
Intervention 
2 
12 
Follow-up 
8 
12 
 

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23 
References 
 
Allison, T., Puce, A. and McCarthy, G. (2000) Social perception from visual cues, role of the STS region. 
Trends in Cognitive Sciences, 4, 267-278. 
Ashwin, C., Baron-Cohen, S., Wheelwright, S., O'Riordan, M., & Bullmore, E. T. (2007). Differential 
activation of the amygdala and the 'social brain' during fearful face-processing in Asperger 
Syndrome. Neuropsychologia, 45(1), 2–14 
Baron-Cohen, Simon (1995) Mindblindness: an essay on Autism and Theory of Mind. MIT Press/Bradford 
Books, Boston. 
Baron-Cohen, S., Wheelwright, S., Hill, J., Raste, Y., and Plumb, I. (2001) The "Reading the Mind in the 
Eyes" Test revised version: a study with normal adults, and adults with Asperger syndrome or 
high-functioning autism. Journal of child psychology and psychiatry, and allied disciplines, 
42(2):241-51. 
Beck, A., R. Steer, and G. Brown, Manual for Beck Depression Inventory-II. 1996, Psychological 
Corporation: San Antonio, TX. 
Bookheimer, S. Y., Ting Wang, A., Scott, A., Sigman, M., & Dapretto, M. (2008). Frontal contributions to 
face processing differences in autism: evidence from fMRI of inverted face processing. Journal of 
the International Neuropsychological Society, 14, 922–932. 
Bray, S., Shimojo, S., O'Doherty, J.P., (2007). Direct instrumental conditioning of neural activity using 
functional magnetic resonance imaging-derived reward feedback. Journal of Neuroscience, 27, 
7498-7507. 
Dapretto, M., Davies, M., Pfeifer, J., Scott, A., Sigman, M., Bookheimer, S., and Iacoboni, M. (2006) 
Understanding emotions in others: mirror neuron dysfunction in children with autism spectrum 
disorders. Nature neuroscience, 9(1):28-30. 
deCharms, R.C., Christoff, K., Glover, G.H., Pauly, J.M., Whitfield, S., Gabrieli, J.D., (2004). Learned 
regulation of spatially localized brain activation using real-time fMRI. Neuroimage, 21, 436-443. 
deCharms, R.C., Maeda, F., Glover, G.H., Ludlow, D., Pauly, J.M., Soneji, D., Gabrieli, J.D., Mackey, S.C., 
(2005). Control over brain activation and pain learned by using real-time functional MRI. Proc. 
Natl. Acad. Sci. U.S.A. 102, 18626-18631. 
Formisano, E., De Martino, F., Valente, G., (2008). Multivariate analysis of fMRI time series: classification 
and regression of brain responses using machine learning. Magnetic Resonance Imaging 26, 921-
934 

rt-fMRI NF intervention study in ASD 
V1.2, 14.02.17 Page 36 
 
Golan, O., Baron-Cohen, S., and Golan, Y. (2008) The 'Reading the Mind in Films' Task [child version]: 
complex emotion and mental state recognition in children with and without autism spectrum 
conditions. Journal of autism and developmental disorders, 38(8):1534-41. 
Hamilton, J.P., Glover, G.H., Hsu, J.-J., Johnson, R.F., Gotlib, I.H., (2011). Modulation of subgenual 
anterior cingulate cortex activity with real-time neurofeedback. Hum. Brain Mapp. 32, 22-31. 
Haviland, J. and Lelwica, M. (1987) The induced affect response: 10-week old infants' responses to three 
emotion expressions. Developmental Psychology, 23(1):97-104. 
Haxby, J. V., Hoffman, E. A., & Gobbini, M. I. (2000). The distributed human neural system for face 
perception. Trends in Cognitive Sciences, 4(6), 223–233. 
Haynes, J., Rees, G., (2006). Decoding mental states from brain activity in humans. Nature Reviews 
Neuroscience, 7, 523-534. 
Herba, C., Landau, S., Russell, T., Ecker, C., and Phillips, M. (2006) The development of emotion-
processing in children: effects of age, emotion, and intensity. Journal of child psychology and 
psychiatry, and allied disciplines, 47(11):1098-106. 
Heuchert, J. and D. McNair, Profile of Mood States 2nd Edition. 2012, North Tonawanda, NY: Multi-
Health Systems Inc. 
Hubl, D., Bolte, S., Feineis-Matthews, S., Lanfermann, H., Federspiel, A., Strik, W., et al. (2003). 
Functional imbalance of visual pathways indicates alternative face processing strategies in autism. 
Neurology, 61, 1232–37. 
Johnston, S.J., Boehm, S.G.,Healy,D., Goebel, R., Linden,D.E., (2010). Neurofeedback: a promising tool 
for the self-regulation of emotion networks. Neuroimage 1066-1072. 
Johnston, S., Linden, D., Healy, D., Goebel, R., Habes, I., Boehm, S., (2011). Upregulation of emotion 
areas through neurofeedback with a focus on positive mood., Cognitive, affective & behavioral 
neuroscience, 11, 44–51 
LaConte, S., Peltier, S.J., Hu, X.P., (2007). Real-time fMRI using brain-state classification. Hum. Brain 
Mapp. 28, 1033-1044. 
LaConte, S., (2011). Decoding fMRI brain states in real-time. NeuroImage, 56, 440-454. 
Luciano, J.V., et al., Development and validation of the thought control ability questionnaire. Personality 
and Individual Differences, 2005. 38(5): p. 997-1008. 
Moll, J., Weingartner, J. H., Bado, P., Basilio, R., Sato, J. R., Melo, B. R., … Zahn, R. (2014). Voluntary 
enhancement of neural signatures of affiliative emotion using FMRI neurofeedback. PloS One, 
9(5), e97343. doi:10.1371/journal.pone.0097343 

rt-fMRI NF intervention study in ASD 
V1.2, 14.02.17 Page 37 
 
Pierce, K., Muller, R. A., Ambrose, J., Allen, G., & Courchesne, E. (2001). Face processing occurs outside 
the fusiform ‘face area’ in autism: evidence from functional MRI. Brain, 124, 2059–2073. 
Pierce, K., & Redcay, E. (2008). Fusiform function in children with an autism spectrum disorder is a 
matter of “who.”. Biological Psychiatry, 64, 552–560. 
Posse, S., Fitzgerald, D., Gao, K., Habel, U., Rosenberg, D., Moore, G.J., Schneider, F., (2003). Real-time 
fMRI of temporolimbic regions detects amygdala activation during single-trial self-induced 
sadness. Neuroimage 18, 760-768. 
Rimland, B. and M. Edelson, The Autism Treatment Evaluation Checklist (ATEC) 1999, San Diego, CA: 
Autism Research Institute. 
Saitovitch, a, Bargiacchi, a, Chabane, N., Brunelle, F., Samson, Y., Boddaert, N., & Zilbovicius, M. (2012). 
Social cognition and the superior temporal sulcus: implications in autism. Revue Neurologique, 
168(10), 762–70. doi:10.1016/j.neurol.2012.07.017 
Scharnowski, F., Hutton, C., Josephs, O., Weiskopf, N., Rees, G., (2012). Improving visual perception 
through neurofeedback. The Journal of neuroscience: the official journal of the Society for 
Neuroscience 32, 17830-17841. 
Schultz, R. T., Gauthier, I., Klin, A., Fulbright, R. K., Anderson, A. W., Volkmar, F., et al. (2000). Abnormal 
ventral temporal cortical activity during face discrimination among individuals with autism and 
asperger syndrome. Archives of General Psychiatry, 57(4), 331–40. 
Sitaram, R., Veit, R., Stevens, B., Caria, A., Gerloff, C., Birbaumer, N., Hummel, F., (2012). Acquired 
control of ventral premotor cortex activity by feedback training: an exploratory real-time fMRI and 
TMS study. Neurorehabil. Neural Repair 26 (3), 256-265. 
Sparrow, S., Balla, D., & Cicchetti, D. (1984). Vineland Adaptative Behaviour Scales: Interview edition, 
Survey form.  Circle Pines, MN: American Guidance Service. 
Wang, T., Dapretto, M., Hariri, A., Sigman, M., and Bookheimer, S. (2004) Neural correlates of facial 
affect processing in children and adolescents with autism spectrum disorder. Journal of the 
American Academy of Child and Adolescent Psychiatry, 43(4):481-90. 
Wechsler, D., Wechsler Adult Scale of Intelligence. 1997, San Antonio, TX: The Psychological 
Corporation. 
Weiskopf, N., (2012). Real-time fMRI and its application to neurofeedback. Neuroimage 62, 682-92. 
Weiskopf, N., Mathiak, K., Bock, S.W., Scharnowski, F., Veit, R., Grodd, W., Goebel, R., Birbaumer, N., 
(2004). Principles of a brain–computer interface (BCI) based on real-time functional magnetic 
resonance imaging (fMRI). IEEE Trans. Biomed.Eng. 51, 966-970. 

rt-fMRI NF intervention study in ASD 
V1.2, 14.02.17 Page 38 
 
Weiskopf, N., Veit, R., Erb, M., Mathiak, K., Grodd, W., Goebel, R., Birbaumer, N., (2003). Physiological 
self-regulation of regional brain activity using real-time functional magnetic resonance imaging 
(fMRI): methodology and exemplary data. Neuroimage 19, 577–586. 
Wells, A. and M.I. Davies, The Thought Control Questionnaire: a measure of individual differences in the 
control of unwanted thoughts. Behav Res Ther, 1994. 32(8): p. 871-8. 
Yoo, S.S., Fairneny, T., Chen, N.K., Choo, S.E., Panych, L.P., Park, H., Lee, S.Y., Jolesz, F.A., (2004). Brain-
computer interface using fMRI: spatial navigation by thoughts. Neuroreport 15, 1591-1595. 
Young A, Perrett D, Calder A, Sprengelmeyer R, Ekman P: Facial expressions of emotion: stimuli and tests 
(FEEST). Suffolk, England: Thames Valley Test Company; 2002 
Zigmond, A.S. and R.P. Snaith, The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 
1983. 67(6): p. 361-70. 
Zilbovicius, M., Saitovitch, A., Popa, T., Rechtman, E., Diamandis, L., Chabane, N., Brunelle, F., Samson, 
Y., Boddaert, N, (2013). Autism, social cognition and superior temporal sulcus, Open Journal of 
Psychiatry, 3, 46-55 
 
24 
Appendices 
 
Informed Consent Form 
 
Ethical Committee Approval