Efficacy and Mechanism of Repeated Transcranial Magnetic Stimulation in Children With Autism Spectrum Disorder: an Open-label Clinical Trial(Ⅱ)
Phase: NA
Conditions: Autism Spectrum Disorder
Sponsor: Xinhua Hospital, Shanghai Jiao Tong University School of Medicine

Efficacy and mechanistic of repeated transcranial magnetic stimulation in children with autism
spectrum disorder: an open-label clinical trial. NCT05472870
Version: 2.0/April 2, 2022
PROTOCOL TITLE:
Efficacy and mechanistic of repeated transcranial magnetic
stimulation in children with autism spectrum disorder: an
open-label clinical trial
NCT NUMBER: 05472870
PRINCIPAL INVESTIGATOR:
Fei Li, PhD
Xinhua Hospital affiliated to Shanghai Jiao Tong University
School of Medicine, Chief Physician
feili@shsmu.edu.cn
Ti-fei Yuan, PhD
Shanghai Mental Health Center, Professor
ytf0707@126.com
VERSION NUMBER:
Version 2.0
VERSION DATE:
April 2, 2022

Efficacy and mechanistic of repeated transcranial magnetic stimulation in children with autism
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Version: 2.0/April 2, 2022
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STUDY SUMMARY
Study Title
Efficacy and mechanisms of repeated transcranial magnetic
stimulation in children with autism spectrum disorder: an
open-label clinical trial
Primary Objective
Preliminarily explore whether accelerated continuous theta-burst
stimulation (a-cTBS) over left primary motor cortex (M1) can
improve clinical symptoms of children with autism spectrum
disorder (ASD) in China.
Secondary Objective
Explore the appropriate intervention model, effective adaptation
population and underlying neurological mechanisms of repeated
transcranial magnetic stimulation (rTMS) for ASD children.
Sample Size
≥30 individuals
Trial Design
This study is a single-arm open-label clinical trial, designed to
enroll at least 30 children with ASD aged over 4 years old.
The children seen in our outpatient clinics, who meet the
DSM-5 ASD diagnostic criteria with ADOS and strict
inclusion/exclusion criteria, can be enrolled for the intervention
after informed consent.
During the trial, participants will receive accelerated
continuous theta-burst stimulation (a-cTBS)on the left primary
motor cortex (M1) for 5 consecutive days and complete clinical
assessments within 2 weeks before the cTBS intervention
(pre-cTBS), repeated within 3 days after the completion of the
cTBS course (post-cTBS) and 1 month following the last cTBS
session (one month follow-up), respectively.
Outcome measures
The primary outcome measure is the parent-reported Social
Responsiveness Scale (SRS) score at pre-intervention,
immediately after the 5 days of intervention and 4 weeks after the
5 days of intervention.
Secondary outcome measures are Childhood Autism Rating
Scale (CARS) ; Repetitive Behaviors Scale-Revised (RBS-R);
Conners parent symptom questionnaire (PSQ), Behavior Rating
Inventory of Executive Function(BRIEF), Peabody Picture
Vocabulary Test (PPVT); Chinese Communication Development
Inventory (CCDI) ; Clinical Efficacy Rating Scale (CGI) scores.
Exploratory indicators are changes in resting-state
Electroencephalogram (EEG) characteristics before and after the
intervention, and Multilingual Assessment Instrument for
Narratives (MAIN) scores.
Safety Evaluation
During the intervention and follow-up periods, a careful
physical examination will be conducted by clinician when
participants come to the hospital. Meanwhile, A semi-structured

Efficacy and mechanistic of repeated transcranial magnetic stimulation in children with autism
spectrum disorder: an open-label clinical trial. NCT05472870
Version: 2.0/April 2, 2022
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interview will be administered following each treatment session
and follow-up by the rTMS technician, special attention will be
paid to TMS common discomforts, such as spasms, convulsions,
scalp discomfort, local pain, headache, dizziness, tinnitus,
nausea,etc. If any adverse events or physical discomfort were
reported, detailed descriptions were recorded and graded
according to their severity.
Inclusion criteria
A. Children aged ≥4 years old
B. Meet the diagnostic criteria for ASD of the DSM-5
C. ASD Diagnosis confirmed by the Autism Diagnostic
Observation Schedule (ADOS) or Autism
Diagnostic Interview, Revised (ADI-R)
D. Provide written informed consents
Exclusion criteria
A. With metal implants in the body
B. History of epilepsy or other neurological disease
C. Require surgical treatment due to structural
abnormalities indicated by brain MRI
D. With genetic or chromosomal abnormalities
E. With psychiatric/mental disorder (e.g., very
early-onset schizophrenia) other than ASD
F. Suffer from serious heart disease and/or severe
hearing impairment
G. Intracranial hypertension
H. Participating in other clinical trials
I. Participants who received other interventions within
4 weeks prior to enrollment.
Intervention
Participants will receive cTBS over the left M1for 5 consecutive
days. The detailed parameters as follows: 80% of RMT, 60 cycles
of 10 bursts of three pulses at 50 Hz were delivered in 2-second
trains (5 Hz) with no intertrain interval (i.e. triplet standard cTBS,
1800 pulses, 120s). Stimulation sessions were delivered hourly,
10 sessions were applied per day (18,000 pulses/day).
Research time
Expect to recruit at least 30 ASD children from May 2022 to
December 2023. A total of approximately 5 weeks per subject
will spend to complete a baseline assessment, a 5-day
intervention, and a 4-week follow-up after the intervention.

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Version: 2.0/April 2, 2022
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ABBREVIATIONS/DEFINITIONS
ASD
Autism spectrum disorder
ADOS
Autism Diagnostic Observation Schedule
ADI-R
Autism Diagnostic Interview, Revised (ADI-R)
AE
Adverse Events
a-cTBS
Accelerated continuous theta-burst stimulation
BRIEF
Behavior Rating Inventory of Executive Function
CCDI
Chinese Communication Development Inventory
CGI
Clinical Efficacy Rating Scale
cTBS
Continuous theta-burst stimulation
DSM-5
Diagnostic and Statistical Manual of Mental Disorders
5th Edition
EEG
Electroencephalogram
M1
Primary motor cortex
MAIN
Multilingual Assessment Instrument for Narratives
PSQ
Conners parent symptom questionnaire
PPVT
Peabody Picture Vocabulary Test
RBS-R
Repetitive Behaviors Scale-Revised
rTMS
Repeated transcranial magnetic stimulation
SRS
Social Responsiveness Scale
SAE
Serious Adverse Events
TMS
Transcranial magnetic stimulation

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Catalogue
1.0
Background - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 5
2.0
Objectives- - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - 8
3.0
Study design- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 8
Appendix: study design flow - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 9
4.0
Study subjects- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 10
4.1 Indications- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 10
4.2 Sample size and calculation method- - - - - - - - - - - - - - - - - - - - - - - - - - - - 10
4.3 Inclusion criteria- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 10
4.4 Exclusion criteria- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -10
4.5 Exit criteria- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -11
4.6 Case rejection criteria- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -11
5.0
Intervention - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -11
5.1 Intervention program- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -11
5.2 Combined treatment- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 11
6.0
Follow-up plan- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 12
6.1 Follow-up time arrangement- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -12
6.2 Follow-up content: Process schedule- - - - - - - - - - - - - - - - - - - - - - - - - - - - 12
7.0
Outcome measures- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -12
7.1 Primary outcome measures- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -12
7.2 Secondary outcome measures- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -13
7.3 Exploratory outcome measures- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 14
8.0
Safety evaluation - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 14
8.1 Physical Signs- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 14
8.2 Adverse events incidence- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -14
9.0
Adverse events and serious adverse events- - - - - - - - - - - - - - - - - - - - - - - - -14
9.1 Definition of adverse events- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -14
9.2 Record of adverse events- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 14
9.3 Serious Adverse Events- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 15
10.0
Ethical Committee and informed consent- - - - - - - - - - - - - - - - - - - - - - - - -15
10.1 Ethical Committee- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -15
10.2 Informed consent- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 15
11.0
Data management and statistical analysis- - - - - - - - - - - - - - - - - - - - - - - - -15
11.1 Data Collection- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -16
11.2 Data Monitoring and Auditing- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -16
11.3 Selection of statistical analysis data- - - - - - - - - - - - - - - - - - - - - - - - - - - -16
11.4 Statistical analysis of the population- - - - - - - - - - - - - - -- - - - - - - - - - - - - 16
11.5 Statistical analysis method- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 16
12 Principal Investigator and contact person- - - - - - - - - - - - - - - - - - - - - - - - - - - 17
12.1 Principal Investigator- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -17
12.2 Project leader- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 17

Efficacy and mechanistic of repeated transcranial magnetic stimulation in children with autism
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Efficacy and mechanistic of repeated transcranial magnetic
stimulation in children with autism spectrum disorder: an
open-label clinical trial
1.0
Background
Autism spectrum disorder (ASD), also known as childhood autism, was first
reported and named by American psychiatrist Kanner in 1943. It is a
neurodevelopmental condition with a specific combination of impairments in social
communication and repetitive behaviors, highly restricted interests and/or sensory
behavior, beginning early in life. In recent years, the global incidence of autism in
children has been rising sharply, affecting approximately 1/100 children around the
world and more in some countries and districts [1]. Moreover, a significant proportion
of ASD children have a combination of different degrees of intellectual impairment,
who need more attention and care, bringing heavy burden to families and society [2].
Currently, it is believed that individualized precise treatment based on etiology
is the most recommended way to treat neuropsychiatric diseases including ASD[3].
However, ASD is thought to be the result of a combination of many factors acting on
the nervous system, including the individual's genetic background, adverse
environment, so there is a significant heterogeneity on the behavioral symptoms and
severity phenotype of children with ASD, which further increases the difficulty of
diagnosis and treatment. So far, there are few highly evidence-based and effective
treatment for ASD worldwide[4], especially for core social communication symptom,
and children’s treatment is still based on symptomatic behavioral intervention, such as
behavioral analysis therapy (ABA), Denver early intervention mode, etc. Many
families cannot afford or do not have access to professional intervention, and only
small-to-medium effects of improvement have been achieved despite some children
received timely high-intensity interventions. Therefore, it is imperative to find new
treatments that are safe, tolerable, fast acting, durable, and effective.
Repetitive
transcranial
magnetic
stimulation
(rTMS),
a
non-invasive
neuromodulation technology, has been proposed as potential therapeutic options for
the modification of the pathological neuroplasticity involved in neuropsychiatric
disorders including ASD[5], and the use of rTMS in patients is relatively well
tolerated and safe [6,7]. Consistant Theta-burst stimulation (cTBS) is a more efficient
form of rTMS that produces stronger brain plasticity changes through lower overall
stimulation intensity and shorter stimulation duration[8]. To date, There are many
rTMS studies on dorsolateral prefrontal cortex (DLPFC), which found that the
intervention group improved in social interaction, cognitive and executive function,
repetitive and stereotyped behavior to varying degrees, and had good clinical benefits
in ASD [9-13]. We noticed the primary motor cortex (M1) might be a potential
stimulation target for two reasons: 1) atypical neuroplasticity was observed in M1 in
autistic individuals using TMS[14,15]; 2)M1 is highly involved in the processing of

Efficacy and mechanistic of repeated transcranial magnetic stimulation in children with autism
spectrum disorder: an open-label clinical trial. NCT05472870
Version: 2.0/April 2, 2022
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action execution[16] and emotion evaluation[17-18]. However, there has been no
clinical trial targeting M1 examined the efficacy of improving ASD symptoms.
Given the scarcity of studies on rTMS stimulation over M1 and the lack of trials
examining its efficacy, especially in social communication impairment, we design this
single-arm open-label trial to investigate the efficacy and safety of an accelerated and
high-dose continuous Theta-burst stimulation (a-cTBS) targeting left M1 for autistic
core deficits in ASD children. Before drafting this protocol, our group has included 20
high-functioning ASD children aged 6-10 years old to receive cTBS on M1 in 10
consecutive days [NCT05238298], the results suggested that more than half of the
children had improvement in social and language function, meanwhile, it was safe and
well tolerated. The above research experience provide a guarantee for the
implementation of this trial.
References
[1] Maenner MJ, Shaw KA, Bakian AV, et al.Prevalence and Characteristics of
Autism Spectrum Disorder Among Children Aged 8 Years — Autism and
Developmental Disabilities Monitoring Network, 11 Sites, United States, 2018.
Surveillance Summaries,2021,70(11): 1-16.
[2]Khan NZ, Gallo LA, Arghir A, et al.Autism and the grand challenges in global
mental health[J].Autism Res,2012,5(3): 156-159.
[3]Beversdorf DQ.Phenotyping, Etiological Factors, and Biomarkers: Toward
Precision Medicine in Autism Spectrum Disorders[J].Journal of Developmental and
Behavioral Pediatrics,2016,37(8): 659-673.
[4] Frye RE. Social Skills Deficits in Autism Spectrum Disorder: Potential Biological
Origins and Progress in Developing Therapeutic Agents. CNS Drugs. Aug
2018;32(8):713-734. doi:10.1007/s40263-018-0556-y.
[5] Oberman LM, Enticott PG, Casanova MF, et al.Transcranial magnetic stimulation
in autism spectrum disorder: Challenges, promise, and roadmap for future
research.Autism Res.2016;9(2):184-203. doi:10.1002/aur.1567
[6] Krishnan C, Santos L, Peterson MD, Ehinger M.Safety of noninvasive brain
stimulation in children and adolescents.Brain Stimul.2015;8(1):76-87.
doi:10.1016/j.brs.2014.10.012
[7] Rossi, S., Hallett, M., Rossini, P.M., Pascual-Leone, A., & Safety of
T.M.S.Consensus Group.(2009).Safety, ethical considerations, and application
guidelines for the use of transcranial magnetic stimulation in clinical practice and
research.Clinical Neurophysiology, 120(12), 2008–2039.
doi:10.1016/j.clinph.2009.08.016
[8] Chung SW, Hill AT, Rogasch NC, Hoy KE, Fitzgerald PB.Use of theta-burst
stimulation in changing excitability of motor cortex: A systematic review and
meta-analysis.Neurosci Biobehav Rev.2016;63:43-64.
doi:10.1016/j.neubiorev.2016.01.008
[9] Khaleghi A, Zarafshan H, Vand SR, Mohammadi MR.Effects of Non-invasive
Neurostimulation on Autism Spectrum Disorder: A Systematic Review.Clin
Psychopharmacol Neurosci.2020;18(4):527-552. doi:10.9758/cpn.2020.18.4.527

Efficacy and mechanistic of repeated transcranial magnetic stimulation in children with autism
spectrum disorder: an open-label clinical trial. NCT05472870
Version: 2.0/April 2, 2022
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[10]Kang JN, Song JJ, Casanova MF, Sokhadze EM, Li XL.Effects of repetitive
transcranial magnetic stimulation on children with low-function autism.CNS Neurosci
Ther.2019;25(11):1254-1261. doi:10.1111/cns.13150
[11]Masuda F, Nakajima S, Miyazaki T, et al.Clinical effectiveness of repetitive
transcranial magnetic stimulation treatment in children and adolescents with
neurodevelopmental disorders: A systematic review.Autism.2019;23(7):1614-1629.
doi:10.1177/1362361318822502
[12]Casanova MF, Shaban M, Ghazal M, et al.Effects of Transcranial Magnetic
Stimulation Therapy on Evoked and Induced Gamma Oscillations in Children with
Autism Spectrum Disorder.Brain Sci.2020;10(7):423. Published 2020 Jul 3.
doi:10.3390/brainsci10070423
[13]Gwynette MF, Lowe DW, Henneberry EA, et al.Treatment of Adults with Autism
and Major Depressive Disorder Using Transcranial Magnetic Stimulation: An Open
Label Pilot Study.Autism Res.2020;13(3):346-351. doi:10.1002/aur.2266
[14]Desarkar P, Rajji TK, Ameis SH, et al.Assessing and stabilizing atypical plasticity
in autism spectrum disorder using rTMS: Results from a proof-of-principle study
[published online ahead of print, 2021 May 5].Clin
Neurophysiol.2021;S1388-2457(21)00548-4. doi:10.1016/j.clinph.2021.03.046
[15]Jannati A, Ryan MA, Block G, et al.Modulation of motor cortical excitability by
continuous theta-burst stimulation in adults with autism spectrum disorder.Clin
Neurophysiol.2021;132(7):1647-1662. doi:10.1016/j.clinph.2021.03.021
[16]Fini C, Fischer M, Bardi L, Brass M, Moors A. Support from a TMS/MEP study
for a direct link between positive/negative stimuli and approach/avoidance tendencies.
Neuropsychologia. Jun 2020;143:107496.
doi:10.1016/j.neuropsychologia.2020.107496
[17]Borgomaneri S, Gazzola V, Avenanti A. Temporal dynamics of motor cortex
excitability during perception of natural emotional scenes. Soc Cogn Affect Neurosci.
Oct 2014;9(10):1451-7. doi:10.1093/scan/nst139
[18]Xia X, Wang D, Song Y, et al. Involvement of the primary motor cortex in the
early processing stage of the affective stimulus-response compatibility effect in a
manikin task. Neuroimage. Jan 15 2021;225:117485.
doi:10.1016/j.neuroimage.2020.117485

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spectrum disorder: an open-label clinical trial. NCT05472870
Version: 2.0/April 2, 2022
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2. 0
Objectives
To whether accelerated continuous theta-burst stimulation (a-cTBS) over left
primary motor cortex (M1) can improve clinical symptoms of children with autism
spectrum disorder (ASD) in China, and to investigate the appropriate intervention
model, effective adaptation population and underlying neurological mechanisms of
repeated transcranial magnetic stimulation (rTMS) for ASD children..
3. 0
Study design
This study is a single-arm open-label clinical trial, planned to include at least 30
ASD children aged over 4 years old.
The children seen in our outpatient clinics, who meet the DSM-5 ASD diagnostic
criteria with ADOS and strict inclusion/exclusion criteria, can be enrolled for the
intervention after informed consent.
During the trial, participants will receive accelerated continuous theta-burst
stimulation (a-cTBS)on the left primary motor cortex (M1) for 5 consecutive days and
complete clinical assessments from the baseline to 1 month following the last cTBS
session (Pre-intervention, Post-intervention and one month follow-up, respectively).
The detailed a-cTBS parameters as follows: 80% of RMT, 60 cycles of 10
bursts of three pulses at 50 Hz were delivered in 2-second trains (5 Hz) with no
intertrain interval (i.e. triplet standard cTBS, 1800 pulses, 120s). Stimulation sessions
were delivered hourly, 10 sessions were applied per day (18,000 pulses/day).

Efficacy and mechanistic of repeated transcranial magnetic stimulation in children with autism
spectrum disorder: an open-label clinical trial. NCT05472870
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Attached: Study design Flow
ASD children receive assessment for
eligibility and then enroll

Physical measurements, demographic data, and
medicine/treatment history

Clinical assessment: IQ, ADOS, CARS, RBS-R, SRS, PSQ,
BRIEF, CCDI, PPVT

Exploratory indicators: resting-state EEG, MAIN

Clinical assessment: SRS, RBS-R, PSQ, BRIEF, CGI

Exploratory indicators: resting-state EEG

Safety evaluation
a-cTBS: left M1, 120s / time, 10 times / day, for 5 consecutive days
Figure 1. Study flow
Baseline
Post-intervention
1mth follow-up

Clinical assessment: SRS, CARS, RBS-R, PSQ, BRIEF,
CCDI, PPVT, CGI

Exploratory indicators: resting-state EEG, MAIN

Safety evaluation

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4.0
Study subjects
4.1 Indications
Children with ASD.
4.2 Sample size and calculation method
This study will recruit at least 30 ASD children aged over 4 years old at one trial
center.
Sample size calculation method:
This study is a single-arm, open-label clinical trail and most of previous rTMS
studies included 10-20 ASD patient and found their symptoms had improved after
rTMS intervention. For example, Wang, et al. reported the improvement of language
and social symptoms in 13 children aged 3-12 years with ASD after 15 days (15
rTMS sessions in total) [Wang, et al., Frontiers in Psychiatry 2019], Fahnestock, et al.
found a reduction of the disease severity among 16 children with ASD (mean age: 9
years old) after one-month rTMS intervention (20 sessions in total) [Fahnestock, et al.,
Drug Development Research 2021].
A minimum total sample size was estimated using G*Power, being powered
(80% power and two-sided 5% significance) to detect a moderate (0.5)-to-large (0.8)
standardized effect of treatment. The estimated effect size was guided by existing
study results on social behavior deficits (Ni HC, et al.,Autism, 2021, Barahona-Correa
et al., Front Integr Neurosci, 2018). Considering the 10 % dropout rate and the fact
that this study would include both low-function and high-function ASD children
(further stratified analysis is required), the final sample size of this study is estimated
to be at least 30.
4.3 Inclusion criteria
A.
Children aged ≥4 years old
B.
Meet the diagnostic criteria for ASD of the DSM-5
C.
ASD Diagnosis confirmed by the Autism Diagnostic Observation Schedule
(ADOS) or Autism Diagnostic Interview, Revised (ADI-R)
D.
Provide written informed consents
4.4 Exclusion criteria
A.
With metal implants in the body
B.
History of epilepsy or other neurological disease
C.
Require surgical treatment due to structural abnormalities indicated by brain
MRI
D.
With genetic or chromosomal abnormalities
E.
With psychiatric/mental disorder (e.g., very early-onset schizophrenia) other

Efficacy and mechanistic of repeated transcranial magnetic stimulation in children with autism
spectrum disorder: an open-label clinical trial. NCT05472870
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than ASD
F.
Suffer from serious heart disease and/or severe hearing impairment
G.
Intracranial hypertension
H.
Participating in other clinical trials
I.
Participants who received other interventions within 4 weeks prior to
enrollment.
4.5 Exit criteria
A.
The child had obvious side effects during the intervention
B.
Self-withdrawal (patient withdrawal of consent, etc.)
C.
Lost to visit
D.
Other reasons for the subject's inability to complete the full process of this trial
(e.g., severe somatic disease were found after enrollment)
4.6 Case rejection criteria
A.
Those participants found not to meet the trail criteria after enrollment
B.
Poor compliance, do not cooperate with the protocol to complete the 5-day
intervention course, etc.
5.0
Intervention
5.1 Intervention program
Machine: Pulsed magnetic Stimulation Device (M-100 Ultimate, Shenzhen
Yingchi Technology Co.,Ltd, Shenzhen, China)
Intervention protocol: target left M1, and details of parameter are shown below.
Intensity
Frequency
in the
cluster
Number of
pulses in
the cluster
Inter-
cluster
frequency
Number
of inter-
cluster
pulses
stimulation
time
Inter-
cluster
interval
Repli-
cation
Total
pulses
number
total
time
cTBS
80%MT
50HZ
3
5HZ
200
40s
0
3
1800
120s
Treatment period: 10 times a day, 1 hour interval, a total of 5 days
5.2 Combined treatment
The combined treatment and (or) medication during the study should be detailed
in the case report form, including the name, dose, route of administration, usage, start
and end time of treatment and (or) medication.

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6.0
Follow-up plan
6.1 Follow-up time arrangement
Total of three follow-up time.
-
Follow-up visit 1 (V0): Baseline
-
Follow-up visit 2 (V1): immediately after the 5-day intervention
-
Follow-up visit 3 (V2): 4 weeks after the 5-day intervention
Unscheduled follow-up (USV): No limit on number of times
6.2 Follow-up content: Process schedule
Follow-up time
Follow-up content
V0
V1
V 2
-2w
5d
+4w
Informed consent

Inclusion/exclusion criteria

Demographic data

History taking

check-up

IQ

Autism Diagnostic Observation Schedule (ADOS)/
Autism Diagnostic Interview, Revised (ADI-R)

Childhood Autism Rating Scale (CARS)


Repetitive Behaviors Scale – Revised (RBS-R)



Social Responsiveness Scale (SRS)



Behavior Rating Inventory of Executive Function(BRIEF)



Conners parent symptom questionnaire (PSQ)



Peabody Picture Vocabulary Test (PPVT)


Chinese Communication Development Inventory (CCDI)


Multilingual Assessment Instrument for Narratives (MAIN)


Clinical Efficacy Rating Scale (CGI)


Resting-state EEG



Adverse event

7.0
Outcome measures
7.1 Primary outcome measures:
The Social Responsiveness Scale (SRS) provides the multi-dimensional measure
of social interaction allowing the rating of social impairment in ASD for children aged
4–18 years. It can generate a total raw score and five theoretical subscales scores
(labeled social awareness, social cognition, social communication, social motivation,

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and autistic mannerisms), and higher scores indicates increased social impairment. We
used SRS to monitor the response to the intervention in social domain as it’s able to
measure subtle changes in the severity of symptoms over time. Parents completed
SRS before their child receiving the intervention, immediately after the 5-day
intervention and 4 weeks after the 5-day intervention.
7.2 Secondary outcome measures:
At baseline, Post-intervention, 4-week follow-up:
1) Repetitive Behaviors Scale-Revised (RBS-R) is a questionnaire that is used to
measure the breadth of repetitive behavior in children, adolescents, and adults with
Autism Spectrum disorders. The RBS-R provides a quantitative, continuous measure
of the full spectrum of repetitive behaviors. The RBS-R consists of six subscales
including: Stereotyped Behavior, Self-injurious Behavior, Compulsive Behavior,
Routine Behavior, Sameness Behavior, and Restricted Behavior, that have no overlap
of item content. The higher scores indicating severer symptoms.
2) Behavior Rating Inventory of Executive Function-Parent (BRIEF-P). School
Version contains eight clinical domains that can generate behavioral regulation and
meta-cognition indices and an overall executive composite score; Preschool Version
comprises five subscales that can yields inhibitory self-control, flexibility and
emergent meta-cognition indices and an overall executive composite score), which
provided an ecologically sensitive measure of executive function (EF) performance in
everyday (school/home) environments.
3) Conners Parent Rating Scale (CPRS-48), which provides a qualitative and
quantitative picture of children's emotions and behavior, based on five subscales
assessing: Conduct Problems, Learning Problems, Psychosomatic,
Impulsive-Hyperactive and Anxiety. And CRPS-48 allows for another factor: the
Hyperactivity Index (HI), which includes the 10 items that are considered to be the
most sensitive to treatment effects.
At baseline and 4-week follow-up:
4) Childhood Autism Rating Scale (CARS). CARS is a behaviour-rating scale
used to assess the presence and severity of the symptoms of autism spectrum
disorder(ASD), with scores ranging from 15 to 60 and high scores indicating severe
symptoms. Change of the CARS score from baseline to 1 months after treatment to
evaluate the effect of rTMS treatment on ASD.
5) Chinese Communicative Development Inventory (CCDI), which is a
powerful tool to assess early vocabulary development and the language skills of older
children with developmental disorders and the effectiveness of their interventions;
raw scores were used here allowing us to analysis change in language level over time.
6) Peabody Picture Vocabulary Test (PPVT), one of the most commonly used
assessment tests that measure understanding of single-word. The higher score of
PPVT means better single-word comprehension.
At Post-intervention and 4-week follow-up:
7) Clinical Global Impression Scale (CGI, which consists of 3 items that assess
global illness severity, overall improvement from the start of treatment, and

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therapeutic response( referred to as“CGI-S,”“CGI-I,”and“CGI-E”, respectively),
we use CGI-I to rate how much the patient’s illness has improved or worsened relative
to a baseline measurement (a seven-point scale: 1 = “very much improved” to 7 =
“very much worse”).
7.3 Exploratory outcome measures:
Before receiving the intervention, and 4 weeks after the end of 5-day
intervention, children having certain expression ability need to complete the
Multilingual Assessment Instrument for Narratives (MAIN) to assess narrative
comprehension and production skills.
Resting-state EEG data will be collected before and after the intervention to
investigate the effect of the intervention on brain activity.
8.0
Safety evaluation
8.1 Physical Signs
Careful physical examination of participants will be conducted by clinician at
each visit, with special attention to the inquiry and checking for spasm, convulsions,
scalp discomfort, local pain, headache, dizziness, tinnitus, nausea, etc.
8.2 Adverse events and incidence
A semi-structured interview was administered following each treatment session
and follow-up by the rTMS technician. A standardized adverse events assessment
form was completed if adverse events or physical discomfort were reported. Using
this form, detailed descriptions of the adverse events experienced were recorded,
including rating the event as mild (no impairment, no need stopping trial), moderate
(some impairment, need stopping trial, no need for intervention), severe (evidence of
impairment, need stopping trial and need for intervention).
9. 0
Adverse events and serious adverse events
9.1 Definition of adverse events
Adverse events (Adverse event, AE) are any signs, symptoms or clinical
manifestations that are inconsistent with the treatment purpose, even if there is no
correlation with the treatment, is to be recorded and followed up for their regression.
9.2 Record of adverse events
Record all adverse events that occurred after signing the informed consent form.
The contents of each adverse event record should include the following points:
Duration of the adverse event : start time and end time;
Severity of adverse events:
Mild-no impairment, no need stopping trial
Moderate-some impairment, need stopping trial, no need for intervention
Severe-evidence of impairment, need stopping trial and need for intervention;
Relationship between adverse events and intervention: Investigators assessed the
correlation between adverse events and the intervention as: positive / likely related

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spectrum disorder: an open-label clinical trial. NCT05472870
Version: 2.0/April 2, 2022
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/ possibly related / likely unrelated / unrelated;
Management of adverse events: The investigator should follow up the adverse
events until the symptoms disappear or stabilize; if the adverse event remains at the
end of the study, follow up again within one month after the end of the study.
The intervention used in this study is rTMS, in principle, there is no safety risk
in the use of rTMS in children if the safety guidelines developed by the international
expert panel are strictly adhered to. However, rTMS may bring temporary minor
discomfort such as scalp discomfort, localized pain, dizziness, headache, fatigue,
tinnitus, anxiety, etc., mostly relieved within 24 hours. Serious side effects of seizures
and neurocardiogenic syncope induced during stimulation have also been reported,
but subjects who experienced these two adverse reactions had a history of depression
and/or syncope.
The intervention process of this study is conducted in the hospital, and the
subjects will be closely followed and supported in case of adverse reactions; if
medical treatment is needed, the pediatrician will provide the treatment plan and
follow-up visits. In addition, the study will continue to follow up the adverse events
within 4 weeks after the 5-day intervention.
9.3. Serious Adverse Events
Serious adverse events (SAE) are clinical medical events that occur during the
course of the study that result in death or life-threatening, require hospitalization or
prolonged hospitalization, and cause disability or dysfunctional impairment .
If a serious adverse event occurs during the study, whether related to the
intervention, appropriate treatment measures must be taken immediately and reported
to the principal investigator and the ethics committee within 24 hours.
10.0
Ethics committee and informed consent form
10.1 Ethics committee
Prior to the start of the study, the protocol and informed consent should be
reviewed and approved by the ethics committees of the study centers. During the
study, any change of the study protocol to the Ethics Committee shall be filed with the
Ethics Committee; in case of serious adverse event, the Ethics Committee shall be
notified within 24 hours.
10.2 Informed consent form
Prior to enrollment, the investigator should explain in detail the purpose,
procedure, duration, patient benefits and the possible risks of this trial to children’s
guardians. Informed consent signed in writing by the subject’s legal representative
should be obtained before enrollment in this study.
11. 0
Data management and statistical analysis

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11.1 Data Collection
The data of each subject should be filled in the case report form (CRF) according
to the requirements of the study timely, and the investigators should also keep the
original data (copy) of participants as much as possible to ensure the accuracy of the
CRF data.
11.2 Data Monitoring and Auditing
During the study, the principal investigator and the assisting investigator should
monitor the collection and filling of the data regularly, review the data together with
the statisticians, and complete the final definition and judgment of the analyzed
population.
11.3 Selection of statistical analysis data
Statistical analysis of data from subjects who completed the full 5-day
intervention and follow-up assessments (mainly for primary outcome measure, i.e.,
SRS) .
11.4 Statistical analysis of the population
Analysis of outcome measures: analysis of the population who have completed
the corresponding data collection;;
Safety evaluation: included in the analysis as long as he/her had received one
session of intervention.
11.5 Statistical analysis method
Data will be preprocessed and/or analyzed using SPSS25.0, SAS9.2, Matlab, and
R.
Analysis of the primary outcome measures:
SRS scores at baseline, immediately after the end of 5-day intervention and 4
weeks after the end of 5-day intervention will be analyzed using repeated measures
ANOVA.
Analysis of other behavioral outcome measures:
RBS-R, BRIEF, PSQ scores at baseline, immediately after the end of 5-day
intervention, and 4 weeks after the end of 5-day intervention will be analyzed using
repeated measures ANOVA or Friedman test.
CARS, PPVT, CCDI, MAIN scores at baseline and 4 weeks after the end of 5-day
intervention will be analyzed using paired-samples t-tests or Mann-Whitney Wilcoxon
test.
EEG analysis
EEG data will be preprocessed and analysed by MATLAB. Changes in the
electrophysiologicalactivity characteristics of the brain at baseline, immediately after
the end of 5-day intervention and 4 weeks after the end of 5-day intervention will be
analyzed and then correlated with clinical behavioral outcome.
Safety evaluation
Summarize the occurrence of adverse events: summarize the number of cases,

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instances, and incidence of adverse events and list all adverse events, those related to
the study intervention protocol, serious adverse events, and those leading to exit; list
the number of cases, instances, and incidence of mild, moderate, and serious adverse
events; give a description for adverse events related to the intervention.
Analysis of baseline characteristics
The analysis of baseline characteristics included: demographics (age and gender);
baseline analysis of each observation used in this study.
The number of cases, mean, standard deviation, median, minimum and maximum
values were calculated when the variables were quantitative indicators; the number of
cases and composition ratio were calculated when the variables were categorical
indicators.
12. 0
Principal Investigator and contact person
12.1 Principal Investigator
Fei Li, Chief Physician, Ph.D
Address: Xinhua Hospital, Shanghai Jiaotong University School of Medicine
No. 1665, Jiangjiang Road, Shanghai 200092, China
Tel: 021-25077461, 18930830950
E-mail: feili@shsmu.edu.cn
Ti-Fei Yuan, Professor
Address: Shanghai Mental Health Center, Shanghai Jiao Tong University School of
Medicine, No. 600, Wanping South Road 200030
Tel: 18614086633
E-mail: ytf0707@126.com
Mingyu Xu, Associate Chief Physician
Address: Xinhua Hospital, Shanghai Jiaotong University School of Medicine
No. 1665, Jingjiang Road, Shanghai 200092, China
E-mail: xumingyu@xinhuamed.com.cn
12.2 Project leader
Fei Li, Chief Physician, Ph.D
Address: Xinhua Hospital, Shanghai Jiaotong University School of Medicine
No. 1665, Jiangjiang Road, Shanghai 200092, China
Tel: 021-25077461, 18930830950
E-mail: feili@shsmu.edu.cn