The Impacts of Theta-burst Stimulation Over Posterior Superior Temporal Sulcus on Children and Adolescents With Autism Spectrum Disorder
Phase: NA
Conditions: Autism Spectrum Disorder
Sponsor: Chang Gung Memorial Hospital

 
The Impacts of Theta-burst Stimulation Over Posterior 
Superior Temporal Sulcus on Children and Adolescents 
With Autism Spectrum Disorder 
 
 
ID: NCT03621189 
 
 
 
 
 
 
 
 
 
 
 
 
Hsing Chang Ni 
Department of Psychiatry, Chang Gung Memorial Hospital at Linkou, Taiwan 
 
 
 
 
 
 
 
 
【2020/12/14】 
 
 

NCT03621189 
Study Protocol and Statistical Analysis Plan 
Design 
This was a 4-week randomized, parallel, single-blind and sham-controlled trial, 
followed by another 4-week open-label intervention, to investigate the feasibility and 
efficacy of iTBS over the bilateral pSTS in children and adolescents with ASD at Chang 
Gung Memorial Hospital (CGMH, Linkou, Taiwan). There were 2 phases in this RCT, with 
one-month follow-up. Specifically, after baseline assessments, participants were 
randomized to the Active or Sham group (Phase 1, Baseline-Week 4). Given limited 
human resources, the investigator (H.-C.N.) and his assistant assessed and delivered 
rTMS to all participants. Therefore, only participants and their caregivers were blind to 
the treatment condition (single-blind). Active versus sham iTBS was administered over 
the pSTS 2 days/week for 4 weeks. Entering Phase 2 (Week 5-8), participants were 
unblinded, and then active iTBS over the pSTS were administered to all participants 2 
days/week for the other 4 weeks. This distinct design allowed for a conventional 
rigorous RCT of low risk of bias (Phase 1), and concomitantly resolved a potential 
inequity issue by providing access to iTBS for every participant (Phase 2) (Green, 2008). 
This also enabled investigating effects of longer treatment courses. Considering the 
feasibility based on their school activities, participants freely chose 2 intervention days, 
which are at least 48 hours apart from each other, from Monday to Saturday in the 
beginning of their interventions. Once they made the choice, the schedule of sessions 
was fixed throughout the trial. 
Clinical assessments were completed in participants within one week of the first iTBS 
session of Phase 1 (Baseline) and Phase 2 (Week 5), following the last iTBS session 
(Week 8), as well as at follow-up (Week 12). With the same baseline and follow-up 
assessment schedule, social cognition was specifically measured within 1 hour 
following the last iTBS session of Phase 1 and 2, respectively.  
A minimum total sample size of 68 was estimated using G*Power 3.1 (Faul, Erdfelder, 
Buchner, & Lang, 2009), being powered (90% power and two-sided 5% significance) to 
detect a standardized effect at 0.4 from within-between interaction of the repeated-
measure ANOVA model. The estimated effect size was guided using the pool effect on 
social behavior deficits in existing studies (Barahona-Correa et al., 2018).  
Before implementation, this study was approved by the Research Ethics Committee at 
CGMH (104-9413A) and registered with ClinicalTrials.gov (NCT03621189). The 
procedures and purpose of the study were explained face-to-face to participants and 
their parents, who then provided written informed consents.  
 
Participants 
   We recruited participants, aged 8-17 years, with ASD from the psychiatry 
outpatient clinic of CGMH, Linkou, Taiwan. DSM-IV autistic disorder or Asperger’s 

NCT03621189 
Study Protocol and Statistical Analysis Plan 
disorder, or DSM-5 ASD was clinically diagnosed and corroborated using the Autism 
Diagnosis Objective Schedule (Lord et al., 2000). Exclusion criteria included: FIQ<70 
based on the Wechsler Intelligence Scale for Children-3rd or Wechsler Adult 
Intelligence Scale-3rd (a cutoff at 16 years), any prior history of major neurological 
(especially epilepsy) or medical illness, mood and anxiety disorders, schizophrenia and 
substance misuse. Participants with co-occurring attention-deficit hyperactivity 
disorder (ADHD) were included, and assessed by experienced child psychiatrist (H.-C.N., 
Y.-Y.W., H.-Y.L.). Since there are high psychiatric comorbidities in ASD (70% at least one 
comorbidity), we intended to design the current protocol to strike a balance between 
the generalizability, feasibility, as well as the heterogeneity resulted from the 
psychiatric comorbidities. Therefore, we decided to include those comorbid with 
ADHD, which is the most common co-occurring condition, has similar 
neurodevelopmental nature, and might share some etiologies with ASD, but exclude 
people with the co-occurring conditions which may happen in association with ASD 
but are not inherent in neurodevelopmental conditions (i.e., these disorders happen 
chronologically after ASD). Simultaneously, the effect of iTBS over the pSTS on other 
major psychiatric disorders are unknown, but is well tolerated in people with co-
occurring ADHD (Ni et al., 2017). To minimize potential harms and heterogeneity, 
people with co-occurring mood and anxiety disorders, schizophrenia and substance 
misuse were thus excluded from the current trial. All psychotropic medications were 
continued without change during the trial. All participants had been naïve to any non-
invasive brain stimulation treatment.   
 
Intervention  
    A 70-mm figure-of-eight coil connected to a Magstim Super Rapid2 system 
(Magstim Company, Oxford, UK) was used. Initially, the coil was placed tangentially to 
the scalp over the contralateral motor cortex with the handle pointing backward. The 
location of motor “hot-spot” was determined where single-pulse TMS produced the 
largest motor evoked potentials (MEPs) from the FDI at rest. We measured the active 
motor threshold (AMT) as the minimum stimulation intensity needed to elicit MEPs of 
no less than 200 uV in 5 out of 10 trials during 20% of maximum voluntary contraction 
of the FDI.  
This study administered the iTBS protocol (Huang et al., 2005) as follows: Each TBS 
train was comprised of a burst of 3 TMS pulses at 50 Hz, at 200 ms intervals, for 10 
times. The TBS train was delivered every 10 seconds for 20 times to have 600 pulses in 
total for each iTBS course. In each iTBS session, we first delivered two iTBS with a 3-
minute break over the left pSTS. 5 minutes later, we then delivered the other two iTBS 
over the right pSTS. The intervention pulses in each session were 1200 for each 

NCT03621189 
Study Protocol and Statistical Analysis Plan 
hemisphere (in total 2400 pulses/session; 38400 pulses/study). The stimulus intensity 
of iTBS over the pSTS was 80% of AMT for the active intervention, but 60% AMT for 
the sham intervention. The sham stimulation was still targeted on the bilateral pSTS, 
but delivered with the coil tilted one-wing 90° off the head (Lisanby, Gutman, Luber, 
Schroeder, & Sackeim, 2001), which is a valid sham condition commonly used in 
double- or single-blind sham-controlled RCT across major psychiatric disorders 
(Lefaucheur et al., 2020). This one-wing 90° tilted coil sham manipulation is devoid of 
detectible biological effects (Lisanby et al., 2001) and produces haptic and auditory 
simulation. No any participant assigned in the Sham group at Phase 1 actively disclosed 
or guessed that he or she received the sham stimulation.     
The location of the bilateral pSTS was defined based on the meta-analysis of functional 
MRI (Van Overwalle & Baetens, 2009). These regions were registered to each 
individual’s native structural image in the Navigated Brain Stimulation system 
(Nexstim®, Helsinki, Finland). The details of localization process are reported 
elsewhere (Ni et al., 2017). Whether the lateralization exist in function of the pSTS 
remains elusive. Unlike the target site selection in depression, one recent study 
demonstrated 18 sessions of rTMS applied over bilateral DLPFC produces the most 
striking positive effects on improving symptoms in children and adolescence with ASD 
(E. M. Sokhadze et al., 2018). Furthermore, our prior preliminary study also shows the 
potential therapeutic effects of bilateral pSTS stimulation in adults with ASD (Ni et al., 
2017). We thus followed this principle to set the target site at the bilateral pSTS.  
 
Outcomes 
The primary outcomes included the safety profiles, as well as the social deficits as 
measured by the caregiver-rated Social Responsiveness Scale (SRS) (Gau, 2013), since 
theoretically targeting the pSTS is aimed to modulate the activity within the social 
brain network. Atypical social cognition is often associated with the autistic symptoms. 
The secondary outcomes thus included two common tasks assessing the social 
cognition performances of people with ASD (Barahona-Correa et al., 2018), i.e., the 
Reading the Mind in the Eyes test (RMET) (Baron-Cohen, Wheelwright, Hill, Raste, & 
Plumb, 2001; T. S. Li et al., 2020) and Frith-Happe Animations Task (White, Coniston, 
Rogers, & Frith, 2011) (Barch et al., 2013). Notably, these two tasks, nonetheless, are 
not specific to the pSTS activities. Given our preliminary beneficial results in 
compulsory behaviors in adults (Ni et al., 2017), we also adopted the Repetitive 
Behavior Scale-Revised (RBS-R) (Bodfish, Symons, Parker, & Lewis, 2000; Y. C. Yang et 
al., 2019) as the exploratory outcome. Higher scores on the SRS and RBS-R represent 
greater severity of the two domains of autistic symptoms. RMET total scores represent 
how many correct mental states the participant has inferred from the eyes, indicating 

NCT03621189 
Study Protocol and Statistical Analysis Plan 
individual’s theory of mind capability. Frith-Happe Animations also tap mentalizing 
capacity by asking the participant to infer whether interaction intents exist between 
two triangles. When the participant answered about the presence/absence of 
interactions, he/she was further asked to select words that best described how these 
triangles were feeling at the end of each video clip. Participants scored 1 point for 
correct answers to either presence/absence or exact description of mental states, 
which are summarized as the total Categorical scores and Feelings scores, respectively. 
To enhance a contrast and reduce assessment time, we adopted the revised Frith-
Happe Animations following those used in the Human Connectome Project (Barch et 
al., 2013), which only included social and random interactions.  
    Side effects were assessed immediately after each session and at one-month 
follow-up using open-ended questions inquiring any physical discomfort and then 
close-ended questions including “pain at application site”, “headache/dizziness”, 
“tinnitus” and “anxiety” experienced during and after iTBS  
 
Statistics  
Herein we only reported clinical and cognitive data during RCT. Independent t-test and 
chi-square test were used to evaluate the difference of baseline characteristics. To 
simultaneously examine the immediate effect of pSTS vs. sham stimulation in different 
visits, the generalized estimating equations (GEE) model was conducted using the data 
of Baseline, Week 4, and Week 8. To account for correlations between individuals' 
repeated measurements between visits, a working correlation matrix with a first-order 
autocorrelation was used with the robust estimator of standard error. Treatment, Time, 
and a two-way interaction (Active vs. Sham × Time) effects were modeled in the GEE. 
The maximum likelihood method in the GEE was used to address the missing values 
from dropouts. In consideration of high inter-individual variability in the clinical 
symptoms and social cognitive function at baseline, we also implemented an 
additional analysis using the symmetrized percentage change (Ayers, 2006) to 
investigate the iTBS effects. Because there was significant difference for both groups 
at baseline in the RMET, all of the analyses in the GEE and symmetrized percentage 
change were adjusted.  
To comprehensively examine effects across time for both conditions, exploratory 
within-group comparisons were also conducted in the same GEE regardless of whether 
the main effect was statistically significant. However, when the main effect of GEE is 
not statistically significant, the significant findings in these exploratory within-group 
comparisons should be interpreted conservatively. The correction for multiple 
comparisons was implemented to avoid type-I errors. Five pairwise within-group 
comparisons (i.e., Baseline vs. Week 4, Baseline vs. Week 8, Baseline vs. Week 12, 

NCT03621189 
Study Protocol and Statistical Analysis Plan 
Week 4 vs. Week 8, Week 8 vs. Week 12) were calculated separately in Active (8-week 
active TBS) and Sham (4-week sham followed by 4-week active TBS) groups.  
Considering clinical heterogeneity in ASD, we defined responders based on the 
Reliable Change Index (RCI) calculated using the SRS total scores. The RCI takes into 
consideration the false positive outcome that could occur due to random error from 
repeated measurements alone (Jacobson & Truax, 1991). The RCI represents 
differences in individual’s scores between before- and after-intervention, divided by 
the standard error of the difference of the measure. Responders were those with RCI 
>1.64, which corresponds to p<0.05 with one-sided test (i.e., the null hypothesis was 
that iTBS would not help with social symptoms). Demographic and clinical features 
were compared between the responders and non-responders using non-parametric 
tests.  
 
In addition to the stratified analysis based on responsiveness, we also tested a 
three-way interaction (Active vs. Sham × Time × Modifier) to explore whether iTBS over 
the pSTS is more beneficial for individuals with ASD with certain characteristics. Effect 
modifiers included demographics, intelligence quotient, clinical traits, comorbidity, 
and medication.  
 
Statistical analysis was performed using the SAS Version 9.4 software (SAS 
Institute, Cary, NC, USA). Considering multiple comparisons including the clinical 
symptoms and social cognitive function (5 measurements), the GEE, within-group 
analyses and three-way interaction were considered statistically significant at p-
value≤0.01. Despite contention, herein, alpha level in-between 0.01 and 0.05 were 
considered a nominal significance for hypothesis generating for the future study (Bays, 
2019). 
 
Community involvement 
    There were no community stakeholders involved in the development of research 
questions, study design and outcome measurements. Taipei Parents Association of 
Autism and Foundation for Autistic Children and Adults in Taiwan helped us to 
disseminate the recruitment notice during the study implementation, as well as 
provided the platform for knowledge translation and dissemination of the current 
findings to parent groups after the completion of the study. The progress report has 
been submitted to the funding agency, and the findings have been summarized in a 
user-friendly language and been feedbacked to the participants and their caregivers.  
 
 

NCT03621189 
Study Protocol and Statistical Analysis Plan 
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