2 be preferred over injectable agents. Lenalidomide may be useful in modifying the course of the disease in patients with elevated tumor necrosis factor-alpha (TNF-α) in serum or CSF as well as those patients with other elevated cytokine proﬁle such as Interleukin 1 (IL-1), Interleukin 6 (IL-6), or methyl CpG-binding protein 1 (MeCP-1). The purpose of this phase 2 pilot study is to determine the safety and pharmacodynamics of lenalidomide in chil- dren with autism who have elevated TNF-α levels. We also examine the potential of lenalidomide to reduce TNF-α and improve behavior and speech function. 2. Methods 2.1. Subjects. Subjects consisted of 7 males aged 6 to 12 years with a diagnosis of autism as deﬁned by the DSM-IV- TR and a history of regression in their language and social abilities reported by their parents. The patients had a history of autoimmune dysfunction either in a ﬁrst-degree relative or in their mother either during or after the pregnancy. Because of the history of regression, a thorough evaluation was done in all patients prior to this study to evaluate their autism and rule out degenerative disease. This evaluation included neu- roimaging, 24-hour EEG, genetic testing, metabolic testing, and sampling of serum and CSF to obtain cytokine panels. Patients with elevated CSF TNF-α (>50 pg/mL) noted 0–24 months prior to study onset were asked to be screened for this study. Because a higher percent of males versus females are diagnosed with autism and the potential teratogenic eﬀect of lenalidomide, only males were chosen for this study. Patients with the following conditions were excluded from the study: PPD-NOS and Aspergers by DSM-IV-TR, genetic disorders, active autoimmune conditions such as Crohn’s or Hashimoto’s thyroiditis, or any hematological, hepatic or renal condition that would place subjects at unacceptable risk if they were to participate. Participation was voluntary and without compensation. A Food and Drug Administration Investigational New Drug application was approved for this study (IND102897). Writ- ten informed consent was obtained by the study coordinator from at least one parent of subjects at the baseline visit. The study was approved by the Sutter Health Central Institutional Review Committee. Patient pharmacodynamic data was collected and analyzed by the Celgene Laboratory. Cytokine measurements were analyzed by InterScience Laboratory, Inglewood, CA (CLIA approved), using their commercial protocol for serum and CSF which was frozen and shipped to them. 2.2. Drug and Dosing. Lenalidomide 2.5 mgs was given daily for 12 weeks. This low dose was selected to minimize the risk of adverse eﬀects. In addition, because this was a pilot study, the goal was to test the lowest dose that could potentially lead to improvements. 2.3. Measurements. Baseline behavioral and neuropsycho- logical evaluations included the Receptive and Expressive One-Word Picture Vocabulary Tests, Autism Diagnostic Autism Research and Treatment Observation Schedule (ADOS), the Childhood Autism Rat- ing Scale (CARS), as well as a Clinical Global Impression Improvement (CGI-I). Behavioral and neuropsychological evaluations were measured at the baseline visit and again 6 weeks and 12 weeks after baseline. 2.3.1. Receptive and Expressive One-Word Picture Vocabulary Test. The Receptive One-Word Picture Vocabulary Test [12] is an individually administered, norm-referenced test that provides an assessment of an individual’s English hearing vocabulary. For each item, examinees are presented with a word, spoken by the examiner, along with four illustrations. Examinees select the illustration that depicts the meaning of the word. When examinees are unable to correctly identify the pictured meaning of the word in six out of eight consecutive items, testing is discontinued. For the Expressive One-Word Picture Vocabulary Test [13] examinees are shown a series of illustrations and asked to name each as it is presented. When the examinee is unable to correctly name six consecutive items, testing is discontinued. Both the Expressive and Receptive One-Word Tests are standardized for use with individuals 2 through 18 years of age. 2.3.2. Autism Diagnostic Observation Schedule (ADOS). The Autism Diagnostic Observation Schedule (ADOS) [14] is a semistructured, standardized assessment of communication, social interaction, and play or imaginative use of materials for individuals with possible autism or other pervasive devel- opmental disorders. The ADOS consists of standard activities that allow the examiner to observe behaviors that have been identiﬁed as important to the diagnosis of autism spectrum disorders at diﬀerent developmental levels and chronological ages. The ADOS consists of four modules and each module has its own protocol designed for use with children or adults at a particular developmental and language level, ranging from no expressive language to verbally ﬂuent adults. The examiner selects the module that is most appropriate for a particular child or adult on the basis of his/her expressive language skills and chronological age. Overall ratings are completed immediately after administration. These ratings can then be used to formulate a diagnosis through the use of the diagnostic algorithm provided for each module. 2.3.3. The Childhood Autism Rating Scale. The Childhood Autism Rating Scale (CARS) [15] is used to assess changes in symptoms of autistic disorder. This 15-item behavior rating scale helps to identify children with autism and to distinguish them from other diagnoses. Each item covers a particular characteristic, ability, or behavior. After observing the child and examining relevant information from parent reports and other records, the examiner rates the child on each item. Using a 7-point scale, he or she indicates the degree to which the child’s behavior deviates from that of a normal child of the same age. After the child has been rated on each of the 15 items, a total score is computed by summing the individual ratings. Children who score above a given point