Clinical trial NCT01962870
Conditions: Autism Spectrum Disorders
Sponsor: Stanford University
Start date: 2013-12-01; Completion date: 2017-05-30
Enrollment: 68 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
Researchers at the Stanford University School of Medicine are seeking participants for a study examining the effectiveness of vasopressin, a neuropeptide, in treating children with autism spectrum disorder. Difficulty with social interactions is characteristic of people with autism, who often have problems interpreting facial expressions or maintaining eye contact while talking with someone. There are currently no effective medicines available to treat social problems in individuals with autism. Neuropeptides, such as vasopressin and oxytocin, are molecules used by neurons in the brain to communicate with one another. Vasopressin is closely related to oxytocin, which is currently being tested as a treatment for autism, and has been shown to enhance social functioning in animals. Animal studies have shown that when the proper functioning of vasopressin is experimentally altered, animals develop a variety of social deficits, including impaired memory for peers and a reduced interest in social interaction. Researchers found that when vasopressin was administered to mice with a genetically induced form of autism, their social functioning improved. Vasopressin is already approved by the Food and Drug Administration for use in humans, and has proved to be a successful treatment for some common pediatric conditions, including bedwetting. Similar to oxytocin, it also has been shown to improve social cognition and memory in people who do not have autism. The researchers will test the effects of vasopressin on social impairments in 50 boys and girls with autism, ages 6 to 12 years old. The study will last four weeks for each participant. Participants will receive either vasopressin or a placebo nasal spray. At the end of this phase of the study, those who received the placebo will have the option of participating in a four-week trial during which they will be given vasopressin. Stanford is the only site for the study. Participants do not need to live locally but will need to come to the Stanford University Department of Psychiatry and Behavioral Sciences for study visits.

Detailed description:

Arms: arm 1: Placebo Nasal Spray arm 2: Vasopressin Nasal Spray
Interventions: intervention 1: Vasopressin intervention 2: Placebo
Intervention descriptions: intervention 1: Participants aged 6 to 9.5 years of age will receive the maximum dose of 24 IU (12 IU twice daily). Participants aged 9.6 to 12 years of age will receive the maximum dose of 32 IU (16 IU twice daily). intervention 2: None

Protocol documents:
Prot_001.pdf: 
 
The Role of Vasopressin in the Social Deficits of Autism 
 
NCT01962870 
 
August 2, 2016 
Antonio Hardan, MD, Principal Investigator 
Karen Parker, PhD, Principal Investigator 
Stanford University 
Stanford, California 94305 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


August 2, 2016 
 
Page 2 of 33 
1. 
PURPOSE OF THE STUDY 
a. 
Brief Summary 
We will test the safety and effectiveness of intranasal  
vasopressin treatment for social deficits in children with autism spectrum disorders. This  
research also aims to identify those individuals that stand to benefit most from this drug  
intervention. Vasopressin treatment has enormous potential for enhancing quality of life  
in people with autism through improved social cognition and more meaningful social  
relationships, and if efficacious, will considerably reduce the emotional and financial  
burden of autism on patients, family members, and society. 
b. 
Objectives 
            Vasopressin is one of the most promising candidate drugs to treat the presently  
             intractable social deficits of autism. This project will be the first to test whether  
             intranasal vasopressin administration enhances social functioning in individuals with  
             autism. Inclusion of female participants is a major strength of this study as female  
             exclusion, which frequently occurs in autism treatment studies, may jeopardize optimal   
             testing of effective pharmacotherapies, and preclude identification of disease      
             mechanisms. Our inclusion of females is particularly important because preclinical  
             evidence suggests that males may respond more robustly to vasopressin treatment than  
             females. Additionally, findings from both preclinical and clinical studies have shown that  
             differences in pre-treatment social functioning and/or neuropeptide biology are associated  
             with vasopressin and oxytocin treatment response outcomes. Ours will be the first study  
             to test concomitantly whether pre-treatment social measurements and baseline  
             neuropeptide levels contribute to individual differences in vasopressin treatment response 
             efficacy.  
c. 
Rationale for Research in Humans 
 
                            The purpose of the study is to test the tolerability and effectiveness of intranasal  
                            Vasopressin administration in children with autism spectrum disorders. 
 
2. 
STUDY PROCEDURES 
a. 
Procedures 
We will test the effects of single-dose and 4-week intranasal  
vasopressin administration or placebo on social abilities in 50 high functioning male and  
female participants with autism aged 6 to 12 years. We will use a double-blind, 
randomized, placebo controlled, parallel design with dose-escalation to determine both 
the tolerability and effectiveness of vasopressin treatment for cognitive and behavioral 
problems associated with autism. We plan to enroll and screen up to 100 participants to 
meet our target of 50 randomized subjects.  
 
Before the start of the 4-week dosing period, subjects will be given a 1-week open-
label placebo lead-in to allow for enhanced compliance and efficacy for nasal drug  


August 2, 2016 
 
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administration.  
 
Subjects aged 6 to 9.5 years of age will receive the maximum  
dose of 24 IU (12 IU bid). Subjects aged 9.6 to 12 years of age will receive the 
maximum dose of 32 IU (16 IU bid).  
 
The dose escalation regimen of vasopressin for subjects aged 6  
to 9.5 years is as follows. 
Single dose administration: 12 IU; Week 1: 4 IU twice daily;  
 
Week 2: 8 IU twice daily; Week 3: 12 IU twice daily; and, Week 4: 12 IU twice daily. 
The dose escalation of vasopressin for subjects aged 9.6 to 12 years is as follows. Single 
dose administration: 16 IU; Week 1: 4 IU twice daily; Week 2: 8 IU twice daily; Week 3: 
16 IU twice daily; and Week 4: 16 IU twice daily.  
 
Participants will meet DSM-IV criteria for autism spectrum disorder, confirmed with 
gold standard research diagnostic methods. A comprehensive behavioral  
characterization will be obtained prior to drug administration. The primary outcome  
measure for this study is change in social behavior as determined by parent ratings on the  
Social Responsiveness Scale (SRS) after completion of 4-week vasopressin 
administration.  
 
Secondary outcome measures include changes on other behavioral functioning as 
measured by the clinician administered Clinical Global Impressions (CGI) scale and 
parent ratings on the Repetitive Behavior Scale-Revised (RBS-R), the Spence Children’s 
Anxiety Scale (SCAS), and the Pediatric Quality of Life Inventory 
(PedsQL), Vineland Adaptive Behavior Scale, 2nd Edition (VABS-2) social 
subscale, Aberrant Behavior Checklist (ABC), Multidimensional Social Competence 
Scale (MSCS) following 4-week vasopressin administration and changes in functioning 
on laboratory-based assessments of social behavior and cognition (i.e., social mimicry, 
facial emotion recognition, eye gaze to social cues using eye-tracking technology, social 
memory, and social perceptual abilities including theory of mind) following single-dose 
and 4-week drug administration. Secondary outcome measures also include assessment of 
drug tolerability following single-dose, 1-week, 2-week, 3-week, and 4-week dosing. 
These measures include vital signs (HR/BP and temperature), body-mass index (BMI), 
clinical chemistry labs (NA+, K+, Cl-, BUN, vasopressin), osmolality (urine, blood),  
electrocardiogram (ECG), and parental report of side effects measured using the Dosage  
Record and Treatment Emergent Symptom Scale (DOTES) and the Overt Aggression 
Scale (OAS). Parent ratings on the SRS and the Wing Subgroups Questionnaire (WSQ), 
as well as participant blood samples for neuropeptide quantification, will 
be collected pre-treatment. Pre- treatment scores on the SRS and plasma 
neuropeptide (vasopressin and oxytocin) levels will be used on an exploratory basis to 
predict treatment response outcomes.  
 
After completion of the double-blind 4-week treatment period participants will be  
informed of their treatment group and subjects randomized to placebo will have  
the option of participating in a 4-week open-label vasopressin treatment extension period. 
Participants initially randomized to placebo treatment during the randomized controlled 


August 2, 2016 
 
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trial will undergo vasopressin dose- escalation and safety testing in the open-label 
extension period in a comparative fashion to participants initially randomized to  
vasopressin treatment. Participants who were initially assigned to vasopressin treatment  
during the randomized controlled trial will end the study.  
 
During this time participants will again undergo all previously performed safety 
assessments. This will provide further information regarding the tolerability of longer 
term vasopressin treatment (i.e., up to 8 weeks). During the open-label extension period 
we will conduct pharmacokinetic (PK) analysis to determine the Tmax of vasopressin in 
our study population. The timing of the blood draws during the open-label extension arm 
will take place at 15 minutes post-vasopressin dosing for 1/3 of the participants, at 30 
minutes post vasopressin dosing for 1/3 of the participants, and at 60 minutes post-
vasopressin dosing for 1/3 of the participants. These analyses will take place at week-5, 
week-6, and week-8 for all participants.  
 
Specific aims and hypotheses: To test our overarching hypothesis, we will pursue 
the following aims:  
 
Specific Aim 1. Test the effects of single-dose vasopressin administration on 
laboratory- based social behavior and cognitive measures in children with autism.  
Predictions: Following single-dose vasopressin administration, participants will exhibit 
increased accuracy in recognizing facial emotions, increased eye gaze to social  
cues, enhanced memory for faces and names, increased social mimicry, and enhanced 
social perceptual abilities on theory of mind tasks compared to their  
pre-treatment performance and to the performance of placebo-treated participants.  
 
Specific Aim 2. Test the effects of 4-week vasopressin administration using parent 
ratings of psychosocial and behavioral functioning and laboratory-based social behavior 
and cognition measures in children with autism.  
Predictions: Following 4-week vasopressin administration, participants will exhibit  
improvements in social and behavioral functioning as assessed by and clinician ratings 
on the CGI and parent ratings on the SRS, RBS-R, SCAS, and PedsQL, VABS-2, and 
ABC compared to their performance pre-treatment and as well as compared to 
the performance of placebo-treated participants. Following 4-week vasopressin 
administration, participants will also show improvements on all aforementioned 
laboratory-based measures of social functioning compared to their performance after 
single-dose vasopressin administration and compared to the performance of placebo-
treated participants.  
 
Specific Aim 3. Test the tolerability of single-dose and 4-week intranasal vasopressin 
in children with autism. 
 
Predictions: No significant differences in rates of side effects will be observed between 
vasopressin and placebo treated groups following single-dose and 4-week treatment.  
 
Exploratory Aim 4. Test whether single-dose and/or 4-week vasopressin administration  
preferentially enhances social functioning in male compared to female children with 


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autism. Predictions: Vasopressin treatment will be more effective in male compared to 
female participants consistent with evidence from preclinical studies.  
 
Exploratory Aim 5. Test whether pre-treatment social functioning (i.e., severity of social  
impairments as measured by pre-treatment parent SRS ratings and WSQ social subtype)  
and/or plasma neuropeptide (i.e., vasopressin and oxytocin) levels predict vasopressin 
treatment response efficacy in children with autism.  
 
Methods and procedures:  
Experimental design. Using a double-blind, randomized, placebo controlled, parallel  
design we will test the effects of single-dose and 4-week intranasal vasopressin  
administration on social functioning in children with autism.  
Consent/assent will be obtained before initiating any study procedures. The primary  
outcome measure is change in social behavior as determined by parent ratings on the 
SRS after completion of the 4-week treatment trial. The SRS measures the severity of  
social/communication deficits as they occur in natural environments. The SRS can be  
used as a measure of response to intervention as well as a screening instrument.  
Secondary outcome measures include changes in other behavioral functioning (e.g., 
communication, repetitive/disruptive behaviors, anxiety, quality of life) as measured by 
clinician ratings on the CGI and parent ratings on the RBS-R, SCAS, PedsQL, VABS-2, 
ABC, MSCS after completion of the 4-week treatment trial.  
 
Secondary outcome measures also consist of laboratory-based assessments of social 
behavior and cognition (described below) after both single- dose and 4-week vasopressin 
treatment. Drug tolerability assessments, including vital signs (HR/BP and temperature), 
ECG, and parent report of side effects will be conducted following single- dose, 1-week, 
2-weeks, 3- weeks, and 4-weeks of drug administration. BMI will be assessed after 1-
week, 2-weeks, 3- weeks and 4-weeks of dosing. Clinical chemistry labs and osmolality 
(urine, blood) will be obtained after 1-week, 2-weeks, and 4-weeks of dosing. In cases  
when a blood draw cannot be obtained the urine osmolality (which is highly correlated  
with blood osmolality) will be able to be used as a safety measure. A similar schedule 
will be followed in the optional 4-week open-label extension study.  
 
There will be a total of up to 10 assessment time-points during this study. During the 
first assessment session (screening visit) participants will undergo autism diagnostic 
screening, intelligence testing, medical (history and physical) and psychiatric (history) 
examination (incl. CGI ratings), females of childbearing age or who have started having 
menstrual cycles will undergo urine pregnancy testing; vital signs screening, height  
and weight measurement, ECG assessment, and clinical chemistry labs will be assessed.  
Participants’ will undergo pre-treatment assessment of behavioral and cognitive 
functioning in order to determine baseline levels on the various outcome measures. 
Parent ratings on the SRS, RBS-R, SCAS, PedsQL,VABS-2, ABC, MSCS, WSQ, as well 
as participants’ blood samples for quantification of basal plasma vasopressin and 
oxytocin concentrations will be obtained.  
 
Laboratory measures of social behavior and cognition will be administered to facilitate in 
the analysis of post-treatment changes in functioning by accounting for any pre-existing  


August 2, 2016 
 
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individual differences. Briefly, these laboratory tasks involve assessing the ability of the  
participants to recognize basic emotions from images of faces presented on a computer  
screen. We will also record participants' eye gaze using eye- tracking technology while 
the participants view the emotional faces. We will determine participants’ ability to  
infer emotions after viewing the eye-region of facial stimuli. We will also assess 
participants’ memory for faces and names, and social perception abilities will be assessed 
using tests of theory of mind.  
 
On completion of the screening procedures, subjects and their parents will be instructed 
on administration of a placebo nasal spray and will be provided with a supply of the 
placebo to administer at home. This one week open- label placebo lead-in component will 
enhance compliance and efficacy of nasal drug delivery during the study.  
 
One to four weeks later, participants will return to the clinic and will be randomized in  
a double-blind fashion to a treatment condition (vasopressin or placebo). Stratification 
will be based on gender and age. Prior to drug administration, pre- treatment side effects 
information will be collected with the DOTES and OAS, participants will provide a blood 
sample for neuropeptide quantification and parent SRS ratings will be collected for a 
second time. Neuropeptide levels from the two blood samples and repeated 
parent assessment of the severity of participants’ social impairments will allow us to test 
for stable individual differences in these measures. Parent SRS and WSQ ratings, as well 
as participants’ neuropeptide levels, will allow us to test on an exploratory basis whether 
these baseline measures predict treatment response outcomes. Participants will then  
receive a single-dose of either intranasal vasopressin (12 IU or 16 IU; depending on age) 
or placebo and 20 minutes later will have vital signs (HR/BP and temperature) assessed 
prior to initiating the laboratory behavioral measures.  
 
Before participants leave the clinic they will again have their vital signs assessed (~2 
hours post-dosing) and an ECG will be performed to determine cardiac functioning. 
Parents will be provided with instructions on the dose-escalation schedule that will occur 
at home and will be provided with a dosing schedule that they will be required to follow 
and sign off on each day. Participants will continue vasopressin or placebo administration 
for 4-weeks at home and their parents will be responsible for reporting any adverse 
events to research staff. Parents will also be informed that their children’s free water  
intake should be adjusted downward to decrease the potential occurrence of 
hyponatremia and water intoxication during the treatment period. Following 1- week, 2-
weeks, and 3-weeks of dosing, participants are asked to return to the clinic for visits 
when drug tolerability will be assessed (vital signs, BMI, clinical chemistry labs (not at 
week-3), ECG, and parental side effects reports will be collected. On completion of the 4-
week double-blind treatment period, participants will return to the clinic for assessments. 
Parent SRS, RBS-R, SCAS, VABS-2, ABC, MSCS, and PedsQL ratings and participants 
blood samples will be collected for neuropeptide analysis.  
Participants will be tested on laboratory based social behavior and cognition tests, and  
clinician’s impressions of treatment response will be made using the CGI. Vital signs,  
BMI, clinical chemistry labs, osmolality (urine, blood), ECG, and parental drug side 
effects report will also be monitored to determine drug tolerability.  
 


August 2, 2016 
 
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After completion of the double-blind 4-week treatment period participants will be  
informed of their treatment group and will have the option of participating in a 4-week 
open- label vasopressin treatment extension period. Participants initially randomized to 
placebo treatment during the randomized controlled trial will undergo vasopressin dose-
escalation and safety testing in the open-label extension period in a comparative fashion 
to participants initially randomized to vasopressin treatment. Participants who were 
initially assigned to vasopressin treatment during the randomized controlled trial will  
have the option of continuing on their maximum tolerated dose for an additional 4-  
week open-label extension period. During this time participants will again undergo all  
previously performed safety assessments. This will provide further information 
regarding the tolerability of longer term vasopressin treatment (i.e., up to 8 weeks). 
During the open- label extension period we will conduct PK analysis to determine the 
Tmax of vasopressin in our study population. The timing of the blood draws during the 
open-label extension arm will take place at 15 minutes post- vasopressin dosing for 1/3 of 
the participants, at 30 minutes post-vasopressin dosing for 1/3 of the participants, and at 
60 minutes post-vasopressin dosing for 1/3 of the participants. These analyses will take 
place at week-5, week-6, and week-8 for all participants.  
 
Up to 30 mL of blood will be collected during the blood draws mentioned above. At all 
of the timepoints that blood draws are mentioned above there will also be urine samples 
collected for urine osmolality.  
 
Urine and blood osmolality sample collection at Screening and Weeks 1, 2, 4, 5, 6, and 8 
will be obtained. This will allow for a contingency plan in cases when blood samples are 
not able to be obtained at any given collection time-point since urine osmolality is highly 
correlated with plasma osmolality.  
 
On completion of the 4-week open-label treatment period, participants will return to the  
clinic for assessments including the parent SRS, RBS-R, SCAS, VABS-2, ABC, MSCS 
and PedsQL ratings. Participants will be tested on laboratory based social behavior and 
cognition tests, and clinician’s impressions of treatment response will be made  
using the CGI.  
b. 
Procedure Risks 
Given that this research is the first of its kind to determine the effects of intranasal  
vasopressin for the treatment of social deficits in children with autism, we have chosen  
doses and a treatment duration that we believe will be both safe and effective. Subjects 
aged 6 to 9.5 years of age will receive the maximum dose of 24 IU (12 IU bid). Subjects 
aged 9.6 to 12 years of age will receive the maximum dose of 32 IU (16 IU bid). The 
dose escalation of vasopressin or placebo for subjects aged 6 to 9.5 years is as follows: 
Single dose administration: 12 IU; Week 1: 4 IU twice daily; Week 2: 8 IU twice daily; 
Week 3: 12 IU twice daily; and, Week 4: 12 IU twice daily.  
The dose escalation of vasopressin or placebo for subjects aged 9.6 to 12 years is 
as follows: Single dose administration: 16 IU; Week 1: 4 IU twice daily; Week 2: 8 IU  
twice daily; Week 3: 16 IU twice daily; and, Week 4: 16 IU twice daily. During the 
initial single- dose assessment at the Stanford psychiatry clinic a dose of 12 IU or 16 IU 
of vasopressin or placebo will be administered to the children. This will provide us with 


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an opportunity to determine the tolerability of the highest dose to be used in the study 
while participants are at the psychiatry clinic with medically trained professionals on 
hand and in close proximity to Stanford hospital. This dose- escalation will provide an 
opportunity to determine if an participants have an adverse response to the drug. We also 
have a thorough safety plan in place to deal with any unexpected side effects during the  
initial single-dose and during the outpatient-dosing period (see below).  
 
Safety Monitoring: A medical and psychiatric history will be obtained and a 
physical examination conducted during the screening phase, prior to randomization. All  
participants will be in good general medical health. Additional evaluations will be 
conducted following 1-week, 2-weeks, 3-weeks of dosing and at completion of the 4-
week treatment period. Seizure history will be reviewed carefully during the screening 
visit, and as stated in the protocols exclusion criteria, children with seizure  
disorder, or a history of seizure-like activity, will be excluded. Drug side effects will be 
evaluated with the Dosage Record and Treatment Emergent Symptom Scale  
(DOTES) at screening and following 1-week, 2-weeks, 3-weeks, and 4-weeks of  
dosing. The DOTES is a general rating scale published by the Early Clinical Drug  
Evaluation Unit of the NIMH. The scale has been widely used clinically for children and  
adults to assess many central nervous system (CNS) side effects as well as some 
behavioral side effects. We have modified the original version of the DOTES to include 
specific questions related to potential side effects that might be related to vasopressin 
such as hyponatremia/water intoxication. Vital signs (HR/BP and temperature) will be 
assessed pre-treatment and 20-minutes and ~2 hrs after the first vasopressin dose, as well 
as following 1-week, 2-weeks, 3-weeks, and 4-weeks of dosing. BMI will be assessed at 
screening, 1- week, 2-weeks, 3-weeks, and 4-weeks of dosing. In order to increase safety 
monitoring, blood and urine safety measurement will be conducted during the screening 
phase and after 1-week, 2-weeks, and 4-weeks of dosing. Clinical blood work will assess 
NA+, K+, Cl-, BUN, and vasopressin. Additionally, osmolality (urine, blood) will be 
assessed. In order to determine the impact of vasopressin on heart function, 
ECG recordings will be obtained at screening and following the single- dose, 1-week, 2-
weeks, 3- weeks and 4-weeks of treatment. Finally, based on preclinical animal studies 
there is some evidence to suggest that vasopressin may be involved in the expression of 
aggressive behavior. Although the relationship between vasopressin and aggression in 
humans is currently unknown, we will take every precaution to assess such behavioral 
changes throughout the study.  
The Overt Aggression Scale (OAS) will be administered at screening and following  
1- week, 2-weeks, 3-weeks, and 4-weeks of dosing. The OAS is designed to assess 
observable aggressive or violent behavior and has been used in children with different  
neuropsychiatric disorders.  
Identical safety measures as outlined above will be performed during the optional 4-
week open-label extension study.  
 
Procedures for Handling Adverse Events: Single-dose (initial administration): If, 
following the initial dosing, body temperature changes more than 2°F, heart rate changes 
more than 20 bpm, blood pressure changes more than 20%, or any signs of adverse 
reactions to the drug are noted (e.g., listlessness, vomiting, seizure activity) then close 
monitoring will occur and the participant will be assessed by the study physician. If 


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indicated, participants will be immediately escorted to the Lucile Packard Children’s 
Hospital (LPCH) Emergency Room, for treatment and their participation in the study will 
be terminated. The LPCH Emergency Room is within a short distance from the Stanford 
University Psychiatry and Behavioral Sciences building (~2 blocks), where initial dosing 
will occur. LPCH is a state-of-the-art hospital outfitted with the most advanced medical 
equipment. The hospital employs qualified staff to handle any type of medical emergency 
in children and adolescents.  
 
Outpatient dosing phase: For any adverse events, families will  
be instructed to contact the research coordinator at 650-736-1235 during business hours, 
and through the Stanford page operator after hours and during weekends/holidays. (A 
project coordinator will be available 24/7 to respond to safety concerns.) If the adverse 
event is life threatening, participants will be asked to call 911 or to attend the nearest 
emergency room. If the adverse event is not life threatening, the study coordinator will 
contact the study physician who will contact the family directly and inquire about the 
adverse event. If the study physician judges the side effects as minor or benign, 
a decision will be made whether or not the participant will  
continue in the study. If side effects are judged as severe and might be related to 
vasopressin, the participants will be asked to stop the study drug immediately and will be 
invited to come in to the clinic within 24 hours for a direct evaluation and potential 
termination of their participation in the study. If the study physician feels that the adverse 
event requires immediate medical attention, parents will be instructed to contact 911 or 
go to the nearest emergency room. The study physician will also have the ability to break 
the blind if it is felt that doing so is in the best interest of the participants’ health.  
 
Any serious adverse events will be reported to the Data and Safety Monitoring 
Board (DSMB) and Stanford Institutional Review Board (IRB) within 24 hours and to the 
Food and Drug Administration (FDA) within seven calendar days.  
c. 
Use of Deception in the Study 
No deception will be used.  
d. 
Use of Audio and Video Recordings 
Audio and video recordings will be used during the ADOS and ADI-R assessments. A 
senior clinical psychologist will supervise diagnostic testing. Video recording will be 
used in order to quantify the subject’s social mimicry while they view videos of 
people yawning and laughing. Two independent raters will study the  
videos to assess for mimicry behavior.  
 
The results of these analyses can be shared for scientific purposes, shown in classrooms 
to students for educational purposes, can be shown in public presentations to non-
scientific groups, and can be submitted for public distribution/made available by purchase 
on a DVD.  
 
However, audio and video recordings will not be used for any other purpose or shown 


August 2, 2016 
 
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outside of the research group unless explicit written permission is obtained from both the 
parents and/or children. 
e. 
Alternative Procedures or Courses of Treatment 
f. 
Will it be possible to continue the more (most) appropriate therapy for the 
participant(s) after the conclusion of the study? 
Yes. 
g. 
Study Endpoint(s) 
Primary outcome measure: Social Responsiveness Scale following 4- week vasopressin  
administration.  
 
Secondary outcome measures: The Clinical Global Impressions scale, Repetitive 
Behavior Scale-Revised; Spence Children’s Anxiety Scale, Pediatric Quality of Life 
Inventory, Vineland Adaptive Behavior Scale, 2nd Edition; and Aberrant  
Behavior Checklist following 4-week vasopressin administration and changes in 
functioning on laboratory-based assessments of social behavior and  
cognition (i.e., social mimicry, facial emotion recognition, eye gaze to social cues using  
eye-tracking technology, social memory, and social perceptual abilities including theory 
of mind) following single-dose and 4-week drug administration.  
Secondary outcome measures also include assessment of drug tolerability following 
single- dose, 1-week, 2-week, 3-week, and 4-week dosing. These measures include vital 
signs (HR/BP and temperature), weight, clinical chemistry labs (NA+, K+, Cl-, BUN, 
and vasopressin), electrocardiogram, and parental report of side effects measured using 
the Dosage Record and Treatment Emergent Symptom Scale and the Overt Aggression 
Scale.  
3. 
BACKGROUND  
a. 
Past Experimental and/or Clinical Findings 
Autism is a pervasive developmental disorder characterized by core deficits in social 
behavior and communication, and the presence of repetitive or stereotyped behaviors. 
Autism spectrum disorders affect an estimated 1 in 88 children in the US. Individuals 
with autism demonstrate diminished eye gaze, abnormal facial and emotion processing, 
and impaired social judgment. These deficits jeopardize the development of appropriate 
social skills and maintenance of social relationships.  
Although several medications are approved for the treatment of autism (i.e., the atypical  
antipsychotics risperidone and aripiprazole), none are effective in ameliorating 
the characteristic social deficits. Moreover, these medications have unfavorable side 
effects (e.g., lethargy, weight gain). Identifying the underlying pathophysiology  
of the core social deficits associated with autism and developing new medications that  
target these impairments is clearly an important challenge. The proposed project  
leverages promising preclinical findings to test for the first time whether intranasal 
administration of the neuropeptide vasopressin enhances social functioning in children, 
particularly in males, with autism.  


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Vasopressin has enormous potential for enhancing an individual’s quality of life through  
improved social cognition and more meaningful social relationships. The discovery of  
effective novel therapeutics provides an outstanding opportunity to reduce the emotional 
and financial burden of autism on patients, family members, and society.  
 
Preclinical findings: Vasopressin and oxytocin regulate social behavior and 
show translational promise as pharmacotherapies to treat social impairments. The 
neurobiological systems critical for normative social functioning are arguably the most  
promising candidates by which to identify “drugable” targets to treat autism. Two such  
candidates are vasopressin and oxytocin. Vasopressin and oxytocin are 
primarily synthesized in the hypothalamus and released into the brain via distributed 
neural pathways and systemic circulation via the posterior pituitary.  
Vasopressin and oxytocin are nearly structurally identical nonapeptides and likely 
evolved due to duplication of a common ancestral gene. Extensive animal research over 
four decades has demonstrated the importance of both vasopressin and oxytocin in social 
functioning. Specifically, brain vasopressin and oxytocin systems promote 
social behavior (e.g., partner preference formation, parenting behavior) and social 
cognition (e.g., learning and memory for social information) in a variety of mammalian 
species. In contrast, vasopressin and oxytocin peptide and receptor impairments induced 
by pharmacological or transgenic manipulations produce numerous social deficits in 
animals.  
 
Clinical findings: The behavioral effects of intranasal vasopressin and 
oxytocin administration in neurotypical and patient populations and gaps in our 
knowledge. On the basis of these promising preclinical findings, multiple investigators 
have begun to test the potential of these neuropeptides as therapeutic agents to enhance 
social functioning in people. These studies have mostly focused on the prosocial effects 
of intranasal oxytocin on social functioning in both neurotypical individuals 
and individuals with various psychiatric disorders (e.g., anxiety, schizophrenia, autism).  
Importantly, several independent groups have recently demonstrated that single-doses of 
oxytocin administered to teenage and adult males with autism improve the processing and 
retention of social information, improve emotion recognition when viewing the eye 
region of faces, and increase trust and preference for social partners during a computer 
simulated ball-toss game.  
Several groups, including our own, are now testing the effects of longer-term oxytocin  
administration to younger patients, inclusive of boys and girls, with autism. In contrast  
to oxytocin, there have been only a handful of studies that have investigated the effects of 
intranasal vasopressin on social functioning in humans. Notably, these studies have 
shown that vasopressin enhances memory for happy and angry faces], increases 
recognition of positively and negatively valenced social words, and enhances neural 
activity in known vasopressin brain circuitry during a cooperation task.  
Single intranasal doses of the vasopressin analog desmopressin have also been shown to 
enhance speech and word formation in patients with post-stroke aphasia and  
improve short and long-term memory in patients with central diabetes 
insipidus suggesting potential cognitive enhancing properties of this hormone. In  
humans, intranasally administered vasopressin results in elevated cerebrospinal fluid  
levels of measured vasopressin, strongly suggesting that it achieves access to the brain. 


August 2, 2016 
 
Page 12 of 33 
Importantly, intranasally administered vasopressin and its analogs (e.g., desmopressin) 
are well tolerated in humans with no significant side effects reported in any of the studies 
outlined above. In fact, vasopressin and its analogs have been used for over 30 years in 
both children and adults to treat central diabetes insipidus, nocturnal enuresis, 
and varying states of shock with very few side effects given precautions are adhered to 
(e.g., water restriction to prevent hyponatremia/water intoxication). Surprisingly, despite 
a growing body of evidence documenting the prosocial effects of vasopressin, and the 
relevance of this system to autism, no studies have tested whether vasopressin 
administration enhances social functioning in this disorder. Given the research efforts 
now directed toward testing oxytocin as a treatment for the social deficits in  
autism, there is an obvious need to investigate the treatment potential of this closely 
related neuropeptide to ameliorate the social deficits in autistic individuals.  
 
Why is a vasopressin treatment trial critically needed in patients with autism? In addition 
to its structural and functional similarity to oxytocin, vasopressin merits investigation as a 
candidate drug for use in autism for several other reasons. First, preclinical findings from 
transgenic and wild type animals suggest that important aspects of social cognition are 
mediated through vasopressin V1a receptors.  
In oxytocin receptor null (Oxtr-/-) mice, central administration of either oxytocin or  
vasopressin directly in to the brain improves sociability deficits, enhances exploration of 
social novelty, and reverses cognitive flexibility deficits. Interestingly, pre-treatment with 
a selective V1a receptor antagonist prior to central oxytocin administration almost 
completely attenuates the prosocial and cognitive enhancing effects of oxytocin, 
indicating that V1a receptors mediate this effect. Experiments using wild-type  
mice, rats, and voles likewise show that administration of selective V1a antagonists in 
the presence of normal brain oxytocin signaling impairs social functioning.  
These findings are particularly evident in males, in which vasopressin has been shown to  
selectively regulate social functioning. In fact, an intriguing and important aspect of  
vasopressin and oxytocin physiology is that these neuropeptides exert largely sexually  
dimorphic behavioral effects as determined by a series of influential pharmacological 
and autoradiographical studies. These studies have shown that whereas oxytocin  
preferentially regulates pair bond formation, reproductive physiology (e.g., parturition 
and lactation), and parental care in females, vasopressin preferentially regulates mating 
behavior, pair bond formation, and parental care in male. Second, recent genetic 
association studies suggest that several single nucleotide polymorphisms and their 
haplotypes in the oxytocin receptor gene increase risk for autism. Genome-wide scans 
likewise indicate that the 3p25 region, which contains the oxytocin receptor gene, may be 
a linkage site for autism.  
These findings suggest the intriguing supplementary hypothesis that in patients with 
oxytocin receptor impairments, vasopressin treatment may be even more efficacious than 
oxytocin administration, because although both vasopressin and oxytocin ligands show 
high affinity for all four receptors (i.e., vasopressin: V1a, V1b, V2; and oxytocin:  
OTR, respectively), they bind with greatest affinity to their own receptor(s). This  
hypothesis is further supported by evidence that Oxtr-/- mice have higher vasopressin 
V1a receptor expression in the brain than do wild-type mice suggesting that these animals 
may be more sensitive to vasopressin administration than oxytocin. These findings 
clearly highlight the need for careful studies that clarify the underlying neurobiological 


August 2, 2016 
 
Page 13 of 33 
actions of these neuropeptides as pharmacotherapeutic agents in patients with autism. To 
address this larger research question we must first test whether intranasal vasopressin 
administration improves social functioning in individuals with autism, and whether this 
medication is more efficacious in males compared to females. Factors that contribute to 
treatment response efficacy.  
In addition to gender differences in treatment response, most vasopressin and  
oxytocin pharmacology studies have found treatment responders and non-responders. For 
example, previous preclinical research conducted by our group, and led by Dr. Karen 
Parker, has shown that baseline social phenotype profoundly influences the efficacy of 
vasopressin treatment to induce or enhance pro-social behaviors in male rodents. 
Similarly, a single- dose oxytocin treatment study in male adults with autism provides 
preliminary evidence for enhanced social functioning post- treatment in a subgroup of 
patients who show higher social motivation at baseline. Another recent study using 
transcutaneous electrical acupoint stimulation therapy showed enhanced social 
functioning post-treatment, which was associated with higher plasma vasopressin  
levels in children with autism. Interestingly, treatment benefits and higher vasopressin  
levels were most pronounced in children with “passive” and “aloof”, but not “active but 
odd” behavioral phenotypes as assessed by the WSQ at baseline.  
These findings suggest that individual differences in pre-treatment social impairments 
may contribute to treatment response efficacy and that these changes are associated with  
increased plasma neuropeptide levels. This intriguing hypothesis will be explored in the  
present study as outlined below.  
 
Vasopressin is one of the most promising candidate drugs to treat the presently 
intractable social deficits of autism. This project will be the first to test whether intranasal 
vasopressin administration enhances social functioning in individuals with autism. 
Inclusion of female participants is a major strength of this study as female exclusion, 
which frequently occurs in autism treatment studies, may jeopardize optimal testing of  
effective pharmacotherapies, and preclude identification of disease mechanisms. Our 
inclusion of females is particularly important because preclinical evidence suggests that 
males may respond more robustly to vasopressin treatment than females. Additionally, 
findings from both preclinical and clinical studies have shown that differences in pre-
treatment social functioning and/or neuropeptide biology are associated with vasopressin 
and oxytocin treatment response outcomes. Ours will be the first study to test 
concomitantly whether pre-treatment social measurements and baseline neuropeptide 
levels contribute to individual differences in vasopressin treatment response efficacy.  
b. 
Findings from Past Animal Experiments 
See Section 3.a. 
4. 
RADIOISOTOPES OR RADIATION MACHINES 
a. 
Standard of Care (SOC) Procedures 
Identify Week/Month of Study 
Name of Exam 
Identify if SOC or Research 
N/A 
N/A 
N/A 
b. 
Radioisotopes 


August 2, 2016 
 
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i. 
Radionuclide(s) and chemical form(s) 
N/A 
ii. 
Total number of times the radioisotope and activity will be administered (mCi) and 
the route of administration for a typical study participant 
N/A 
iii. 
If not FDA approved: dosimetry information and source documents (package insert, 
Medical Internal Radiation Dose [MIRD] calculation, and peer reviewed literature) 
N/A 
c. 
Radiation Machines – Diagnostic Procedures 
i. 
Examination description (well-established procedures) 
N/A 
ii. 
Total number of times each procedure will be performed (typical study participant) 
N/A 
iii. 
Setup and techniques to support dose modeling 
N/A 
iv. 
FDA status of the machine and information on dose modeling (if procedure is not 
well-established) 
N/A 
d. 
Radiation Machines – Therapeutic Procedures 
i. 
Area treated, dose per fraction/number of fractions, performed as part of normal 
clinical management or due to research participation (well-established procedures) 
N/A 
ii. 
FDA status of the machine, basis for dosimetry, area treated, dose per fraction and 
number of fractions (if procedure is not well-established) 
N/A 
5. 
DEVICES USED IN THE STUDY 
a. 
Investigational Devices (Including Commercial Devices Used Off-Label) 
Investigational Device  
Name: 
N/A 
Description: 
N/A 
Significant Risk? (Y/N) 
N/A 
Rationale for Non-Significant Risk 
N/A 
 
b. 
IDE-Exempt Devices 


August 2, 2016 
 
Page 15 of 33 
IND-Exempt Device  
Name: 
N/A 
Description: 
N/A 
 
6. 
DRUGS, BIOLOGICS, REAGENTS, OR CHEMICALS USED IN THE STUDY 
a. 
Investigational Drugs, Biologics, Reagents, or Chemicals 
Investigational Product  
Name: 
Vasopressin 
Dosage: 
Subjects aged 6 to 9.5 years of age will receive the 
maximum dose of 24 IU (12 IU bid).  
Subjects aged 9.6 to 12 years of age will receive the 
maximum dose of 32 IU (16 IU bid).  
Administration Route: 
Intranasal  
b. 
Commercial Drugs, Biologics, Reagents, or Chemicals 
Commercial Product  
Name: 
N/A 
Dosage: 
N/A 
Administration Route 
N/A 
New and different use? (Y/N) 
N/A 
7. 
DISINFECTION PROCEDURES FOR MEDICAL EQUIPMENT USED ON BOTH HUMANS AND 
ANIMALS 
N/A 
 
8. 
PARTICIPANT POPULATION 
a. 
Planned Enrollment 
Fifty children with autism spectrum disorders between the ages of 6 and 12 years 
(maximum 12 years and 11 months) will be recruited to participate in this study at 
Stanford. All participants will be enrolled at Stanford. We plan to enroll and screen up to 
100 participants to meet our target of 50 randomized subjects. 
b. 
Age, Gender, and Ethnic Background 
              Males and females from all racial and ethnic backgrounds will be eligible to participate in     
             this study.  
c. 
Vulnerable Populations 
We are recruiting up to 100 potentially decisionally impaired children (ages 6 to 12 
years) with an autism spectrum disorder. This study is specifically directed at children 
with autism in order to test the tolerability and effectiveness of vasopressin in this 
population 
d. 
Rationale for Exclusion of Certain Populations 


August 2, 2016 
 
Page 16 of 33 
N/A 
e. 
Stanford Populations 
N/A 
f. 
Healthy Volunteers 
N/A 
g. 
Recruitment Details 
Potential participants will be identified from the Autism and Developmental Disorders 
Clinic at Stanford and current research registry participants. Flyers will be posted. 
Additionally, subjects may be recruited via the Interactive Autism Network (IAN). The 
IAN Project will inform families about our study in two distinct ways: via e-mail (for 
IAN Research families meeting our study criteria) and via the IAN Community Research 
Opportunities Bulletin Board (for the public at large). If the subject is interested in 
participating they will call the research staff and the research staff will explain the study 
using the advertisement phone script. If the participant is still interested in participating 
then the research staff will obtain their informed consent as outlined above.  
h. 
Eligibility Criteria 
i. 
Inclusion Criteria 
All participants will meet the following: a) medically healthy outpatients between 6 
and 12 years of age (cut off: 12 years and 11 months); b) IQ ≥ 50 (Stanford-Binet); c) 
SRS Total Score ≥ 70; d) ability to complete laboratory and cognitive testing; e) 
diagnosis of ASD based on expert clinical opinion and confirmed on the Autism 
Diagnostic Interview-Revised (ADI-R), Autism Diagnostic Observation Schedule 
(ADOS), and DSM-IV-TR criteria; f) Clinical Global Impression (CGI) severity 
rating of 4 or higher; g) care provider who can reliably bring participant to clinic 
visits, provide trustworthy ratings, and interact with the participant on a regular basis; 
h) stable medications for at least 4 weeks; i) no planned changes in psychosocial 
interventions during the trial; no concurrent participation in any other clinical 
research trials; and, j) willingness to provide blood samples and undergo 
electrocardiogram. 
 
ii. 
Exclusion Criteria 
                                 Participants will be excluded if one or more of the following is met: a) DSM-IV-       
                                 TR  diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, or 
                                 Psychotic disorder; b) regular nasal obstruction or nosebleeds; c) active and 
                                 unstable medical problems (e.g., migraine; asthma; seizure disorder; anaphylaxis;  
                                 epilepsy; diabetes serious liver, renal, or cardiac pathology); d) clinically  
                                 significant abnormal vital signs or ECG reading; e) evidence of a genetic mutation  
                                 know to cause Autism (e.g., Fragile X Syndrome) or metabolic disorder; f) 
                                 significant hearing or vision impairments; g) drinks large volumes of water (e.g.,  
                                 habitual or psychogenic polydipsia); h) pregnant or sexually active females not using 
                                 a reliable method of  contraception (urine pregnancy test will be conducted); i)  


August 2, 2016 
 
Page 17 of 33 
                                 history of hypersensitivity to vasopressin, its analogs (e.g., Desmopressin), or  
                                 compounding preservatives (e.g., chlorobutanol); j) current use of any  
                                 medications know to interact with vasopressin including: 1) carbamazepine (i.e.,  
                                 Tegretol); chlorpropamide; clofibrate; urea; fludrocortisone; tricyclic antidepressants 
                                 (all of which may potentiate the  antidiuretic effect of vasopressin when used    
                                  concurrently); 2) demeclocycline; norepinephrine; lithium; heparin; alcohol (all of  
                                  which may decrease the antidiuretic effect of vasopressin when used concurrently);  
                                  3) ganglionic blocking agents including benzohexonium, chlorisondamine,  
                                  pentamine (all of which may produce a marked increase  in sensitivity to the pressor 
                                  effects of vasopressin); k) prior or current use of AVP; and l) abnormal chemistry 
                                  result.  
i. 
Screening Procedures 
Consents will be obtained before any screening procedures can begin. A review of the 
medical and psychiatric history of participants will take place during the screening 
procedures to determine eligibility to the study. Clinically significant abnormal vital 
signs, ECG readings, and clinical chemistry labs will be determined according to Lucile 
Packard Children’s Hospital (LPCH) standards and expert opinion from trained 
physicians. 
j. 
Participation in Multiple Protocols 
Participants will not be allowed to be enrolled in any other medication or behavioral trials 
during their participation in the current research study.  
k. 
Payments to Participants 
The subjects will be paid $20 for each fully completed study visit. 
l. 
Costs to Participants 
There will be no costs charged to the participants.  
m. 
Planned Duration of the Study 
The entire study will take up to four years to complete and will be followed by a period 
of six months of data analysis. One patient could be in the study for a maximum of 12 
weeks including the initial screening period, the 4-week double-blind treatment trial and 
the optional 4-week open-label extension study. 
9. 
RISKS 
a. 
Potential Risks 
i. 
Investigational devices 
N/A 
ii. 
Investigational drugs 
N/A 


August 2, 2016 
 
Page 18 of 33 
iii. 
Commercially available drugs, biologics, reagents or chemicals 
Vasopressin side effects: There is presently no readily available list of side effects based 
on a common-rare continuum for vasopressin. There are several routes of administration 
for vasopressin: intramuscular (IM), subcutaneous (SC), intravenous (IV), and intranasal 
(IN). In the present study, the IN administration route will be used. There are limited side 
effects associated with the IN route of administration for vasopressin. However, as 
discussed below, there are a number of potential side effects observed when vasopressin 
is administered by injection (i.e., IM, SC, IV). It is crucial to differentiate between the 
side effects specifically associated with different routes of administration.  
 
Intranasal administration: Information regarding the safety profile of IN vasopressin 
administration comes mostly from several clinical trials examining the effectiveness of 
vasopressin for enhancing neurocognitive functioning. Additionally, although the typical 
administration route for treatment of central diabetes insipidus (CDI) is some form of 
vasopressin injection, there are patients (including children) who have primarily used a 
nasal route of administration to treat their disease, or use a vasopressin nasal spray as an 
adjunct to vasopressin injections. Importantly, a large number of studies have provided 
convincing evidence for IN vasopressin being very well tolerated. As mentioned, the 
majority of these studies have aimed to investigate the impact of IN vasopressin on 
neurocognitive processes.  
 
Given the relatively large size of vasopressin (>1 kD), injections of this polypeptide are 
not considered to reach the brain in significant quantities due to the restrictions of the 
blood-brain barrier (BBB). Nasal routes of administration are purported to overcome the 
restrictions of the BBB for large molecule peptides, including vasopressin, making it a 
preferred administration route for targeted CNS treatment. Born et al. provided 
convincing evidence of this by showing that IN vasopressin (40 and 80 IU) administered 
to healthy adult males and females significantly increased CSF concentrations of the 
peptide compared to placebo administration; vasopressin levels had not returned to 
baseline at the end of the 80-minute sampling period. Blood concentrations of 
vasopressin also increased but were only slightly (non-significantly) correlated with CSF 
levels. The nasal route of administration is generally considered much safer than 
injections of vasopressin for multiple reasons; not only is the risk of local infection or 
transfer of contagious blood borne disease substantially reduced, there appear to be far 
fewer peripheral effects noted with IN administration of vasopressin. For example, 
several recent studies have outlined the ability of IN vasopressin (20 and 40 IU) to 
enhance complex psychosocial functioning and associated brain activity when given in 
single-doses to healthy adults. Only minor and transient side effects (relaxation/tiredness, 
increased happiness, headache, dizziness, bitter taste, nasal irritation, increased diastolic 
blood pressure) were reported by a small number of participants and were experienced 
following both administration of vasopressin and placebo.  
 
Chronic dosing with IN vasopressin, as proposed in the current study, has also been 
shown in several studies to be very well tolerated. In a study of 26 elderly individuals 
utilizing a double-blind, randomized, placebo-controlled, 10-week trial of IN vasopressin 
administration (20 IU, bid) for treatment of sleep disturbances, no major side effects were 


August 2, 2016 
 
Page 19 of 33 
reported across multiple safety measures. A self-rating scale of complaints did not reveal 
any side effects of the IN vasopressin treatment. Cardiovascular monitoring revealed a 
systolic blood pressure that was slightly elevated 60 minutes after vasopressin 
administration, but not 8-12 hours later. Measurements of diastolic blood pressure and 
heart rate did not indicate any treatment effects. Examination of blood pressure and heart 
rate on a weekly basis during the 10-week study period revealed values in the normal 
range and no treatment related differences. At the end of the trial, measurement of 
sodium, osmolality, and hematocrit did not reveal any treatment effects, and values were 
entirely within the normal range. Taken together, the studies outlined above suggest that 
IN vasopressin administration at the doses proposed here is very well tolerated. Below is 
a list of side effects reported from a small number of participants following IN 
vasopressin (and placebo) treatment.  
 
Reported side effects following IN vasopressin (and placebo) administration (NB: These 
side effects were all minor and transient):  
• Relaxation or tiredness  
• Headache  
• Dizziness  
• Increased happiness  
• Increased systolic blood pressure  
• Increased diastolic blood pressure  
• Bitter taste  
• Nasal irritation  
 
Vasopressin administered by injection: Ten IU of vasopressin (0.5 mL) given IM will 
usually elicit full physiologic response in adult patients. The manufacturer recommends 
that in the average postoperative adult an initial 5 IU dose, increased to 10 IU if 
necessary, should be given IM every three- or four-hours for treating abdominal 
distention. In preparation for roentgenography, the average patient will require two IM 
injections of 10 IU given two hours and one half-hour, respectively, before films are 
exposed. For treating CDI, vasopressin may be administered SC or IN. The dose of 
injection is 5 to 10 IU repeated two or three times daily as needed. When vasopressin is 
administered IN for treating CDI the dosage and interval should be adjusted for each 
patient.  
Many of the side effects listed by the manufacturer are associated with injections of 
vasopressin and result from its vasoconstrictive properties mediated by vasopressin V1 
receptors. These include cardiac arrest and/or shock, circumoral pallor, arrhythmias, 
decreased cardiac output, angina, myocardial ischemia, and peripheral vasoconstriction. 
Gastrointestinal side effects may include abdominal cramps, diarrhea, intestinal 
hyperactivity, nausea and vomiting. Bronchial constriction, tremor, vertigo and 
“pounding” in the head have also been reported. Skin changes may also occur following 
vasopressin injection and include sweating, urticarial (rash), and cutaneous gangrene. 
Additionally, some individuals may have a severe hypersensitivity to vasopressin or its 
excipients (e.g., chlorobutanol as preservative). In recent years, there has been an 
increase in the use of IV vasopressin treatment for hemodynamically unstable infants and 
children following cardiothoracic surgery. This treatment has been associated with 
reports of water intoxication/hyponatremia associated with prolonged IV vasopressin. 


August 2, 2016 
 
Page 20 of 33 
Careful monitoring of cardiovascular parameters and serum sodium values is important 
when vasopressin is given to intensive care patients or to those with underlying 
cardiovascular pathology or a known sensitivity to the drug or its excipients. For 
outpatients, drinking a glass of water when taking vasopressin is reported to reduce some 
of the skin and gastrointestinal effects. However, close monitoring of fluid intake and 
output should also be considered during vasopressin treatment, and less free water should 
be given, in cases where hyponatremia may be a concern. Importantly, several studies 
have shown that regulation of fluids and close monitoring of electrolyte balance 
substantially reduces the risk of hyponatremia in children being treated with IV 
vasopressin.  
 
Reported side effects following injections (IM, SC, IV) of vasopressin:  
• Abdominal cramps  
• Diarrhea  
• Intestinal hyperactivity  
• Nausea  
• Vomiting  
• Passage of gas  
• Blanching of skin  
• Sweating  
• Tremor  
• Vertigo  
• “Pounding” in head  
• Bronchial constriction  
• Urticarial  
• Circumoral pallor  
• Cutaneous gangrene  
• Anaphylaxis (cardiac arrest and/or shock)  
• Arrhythmias  
• Decreased cardiac output  
• Angina  
• Myocardial ischemia  
• Peripheral vasoconstriction  
• Gangrene  
• Hyponatremia/water intoxication (possibly resulting in seizure or coma)  
 
FDA indications for vasopressin administration: The formulation of vasopressin to be 
used in the proposed research is Vasopressin Injection, USP (American Regent, Shirley 
NY). This drug does not currently have FDA marketing approval for any indication. This 
study is a Phase II clinical trial that aims to investigate both the effectiveness and 
tolerability of IN vasopressin treatment for social, cognitive, and behavioral problems in 
children with autism. Although the FDA has not provided marketing approval for this 
formulation, the manufacturer recommends its use for the prevention and treatment of 
postoperative abdominal distention, CDI, and for abdominal roentgenography to dispel 
interfering gas shadows. Several other US research groups have received FDA approval 
to investigate the effects of IN vasopressin administration for enhancing neurocognitive 
functioning in both healthy adults and patients with autism (e.g., see NCT01327027, 


August 2, 2016 
 
Page 21 of 33 
NCT01566539, NCT01680718, NCT01093768).  
 
Contraindications and precautions for vasopressin administration: The safety concerns 
listed in the section above for vasopressin injections are considered rare if precautions are 
adhered to. The package insert for Vasopressin Injection, USP lists several precautions 
and contraindications associated with this drug. Contraindications for the use of 
vasopressin include anaphylaxis or hypersensitivity to the drug or its components (e.g., 
chlorobutanol as preservative). It is recommended that this drug not be used in patients 
with vascular disease, especially disease of the coronary arteries, except with extreme 
caution. In such patients, even small doses may precipitate angina pain, and with larger 
doses, the possibility of myocardial infarction should be considered. Vasopressin may 
also produce hyponatremia/water intoxication and is contraindicated in patients who 
habitually drink large volumes of water (e.g., habitual or psychogenic polydipsia). For 
this reason, the early signs of drowsiness, listlessness, and headaches should be 
recognized to prevent terminal coma and convulsions. Vasopressin should also be used 
with caution in the presence of epilepsy, migraine, asthma, heart failure, or any state in 
which a rapid addition to extracellular water may produce hazard for an already 
overburdened system. These contraindications are reflected in the extensive exclusion 
criteria and safety monitoring used in this study. Several studies utilizing vasopressin 
treatment in children provide convincing evidence for vasopressin being well tolerated if 
fluid intake is monitored closely during the treatment period.  
 
An additional concern that has been raised with the use of vasopressin is the potential for 
increased aggression. These concerns are based on specific preclinical animal studies; 
however, to the investigators’ knowledge there is no evidence that vasopressin increases 
aggressive behavior when administered to humans. Research on vasopressin and 
aggression in rodents has generally shown that vasopressin increases aggression in: 1) 
non-monogamous adult male residents when an adult male intruder is introduced into his 
“territory” (i.e., home cage), and 2) monogamous adult male residents when an adult 
male intruder is introduced into his territory, which sometimes includes the mate and 
pups. It is arguable that increased aggression in these behavioral assays is adaptive, and 
in the context of the latter example, increased aggression in the presence of mate/pups in 
the home territory is a protective response that is prosocial in nature, at least with regard 
to the resident male’s family. Nevertheless, we acknowledge that monitoring aggression 
in children in our pilot treatment trial is an important precaution. Therefore, we will 
regularly inquire about aggressive behavior throughout the study.  
 
It is important to point out that there is presently no reliable data that outlines 
developmental risks of vasopressin administration in children. The main purpose of our 
study is to determine the safety and efficacy of intranasal vasopressin administration in 
children with autism. Thus, we will report any serious adverse events to the IRB and 
FDA according to law and will detail this information in published articles and 
presentations.  
iv. 
Procedures 
           Brief description of overall plan for the study: We will test the effects of single-dose and       
           4-week intranasal vasopressin administration or placebo on social abilities in 50 high  


August 2, 2016 
 
Page 22 of 33 
           functioning male and female participants with autism aged 6 to 12 years. We will use a  
           double-blind, randomized, placebo controlled, parallel design with dose-escalation to  
           determine both the tolerability and effectiveness of vasopressin treatment for cognitive and  
           behavioral problems associated with autism. We plan to enroll and screen up to 100  
           participants to meet our target of 50 randomized subjects.  
 
 
          Before the start of the 4-week dosing period, subjects will be given a 1-week open- 
          label placebo lead-in to allow for enhanced compliance and efficacy for nasal        
          drug administration.  
 
         Subjects aged 6 to 9.5 years of age will receive the maximum dose of 24 IU (12 IU bid).  
         Subjects aged 9.6 to 12 years of age will receive the maximum dose of 32 IU (16 IU bid).  
         The dose escalation regimen of vasopressin for subjects aged 6 to 9.5 years is as follows:  
         Single dose administration: 12 IU; Week 1: 4 IU twice daily; Week 2: 8 IU twice daily;  
         Week 3: 12 IU twice daily; and, Week 4: 12 IU twice daily. The dose escalation of  
         vasopressin for subjects aged 9.6 to 12 years is as follows: Single dose administration: 16     
         IU; Week 1: 4 IU twice daily; Week 2: 8 IU twice daily; Week 3: 16 IU twice daily; and,  
         Week 4: 16 IU twice daily.  
 
         Participants will meet DSM-IV criteria for autism spectrum disorder, confirmed with gold  
         standard research diagnostic methods. A comprehensive behavioral characterization will be  
         obtained prior to drug administration. The primary outcome measure for this study is       
         change in social behavior as determined by parent ratings on the Social Responsiveness       
         Scale (SRS) after completion of 4-week vasopressin administration.  
 
        Secondary outcome measures include changes on other behavioral functioning as measured      
         by the clinician rated Clinical Global Impressions (CGI)  and the parent ratings on the  
         Repetitive Behavior Scale-Revised (RBS-R), the Spence Children’s Anxiety Scale      
         (SCAS), and the Pediatric Quality of Life Inventory (PedsQL), Vineland Adaptive Behavior  
         Scale, 2nd Edition (VABS-2) social subscale, and the Aberrant Behavior Checklist (ABC),  
        Multidimensional Social Competence Scale (MSCS) following 4-week vasopressin  
        administration and changes in functioning on laboratory-based assessments of social  
        behavior and cognition (i.e., social mimicry, facial emotion recognition, eye gaze to social  
        cues using eye-tracking technology, social memory, and social perceptual abilities including  
        theory of mind) following single-dose and 4-week drug administration. Secondary outcome  
        measures also include assessment of drug tolerability following single-dose, 1-week, 2-     
        week, 3-week, and 4-week dosing. These measures include vital signs (HR/BP and  
        temperature), body-mass index (BMI), clinical chemistry labs (NA+, K+, Cl-, BUN,  
        vasopressin), osmolality (urine, blood), electrocardiogram (ECG), and parental report of side     
        effects measured using the Dosage Record and Treatment Emergent Symptom Scale  
        (DOTES) and the Overt Aggression Scale (OAS).  
         
    
        Parent ratings on the SRS and the Wing Subgroups Questionnaire (WSQ), as well as   
        participant blood samples for neuropeptide quantification, will be collected pre-treatment.  
        Pre- treatment scores on the SRS and plasma neuropeptide (vasopressin and oxytocin) levels  


August 2, 2016 
 
Page 23 of 33 
        will be used on an exploratory basis to predict treatment response outcomes.  
 
        After completion of the double-blind 4-week treatment period participants will be  
        informed of their treatment group and subjects randomized to placebo will have the option of  
        participating in a 4-week open-label vasopressin treatment extension period.   
         
        Participants initially randomized to placebo treatment during the randomized controlled trial  
        will undergo vasopressin dose- escalation and safety testing in the open-label extension     
        period in a comparative fashion to participants initially randomized to vasopressin treatment.  
        Participants who were initially assigned to vasopressin treatment during the randomized  
        controlled trial will end the study. During this time participants will again undergo all  
        previously performed safety assessments. This will provide further information regarding the  
        tolerability of longer term vasopressin treatment (i.e., up to 8 weeks). During the open-label  
        extension period we will conduct pharmacokinetic (PK) analysis to determine the Tmax of  
        vasopressin in our study population. The timing of the blood draws during the open-label  
        extension arm will take place at 15 minutes post-vasopressin dosing for 1/3 of the   
        participants, at 30 minutes post-vasopressin dosing for 1/3 of the participants, and at 60  
        minutes post-vasopressin dosing for 1/3 of the participants. These analyses will take place at  
        week-5, week-6, and week-8 for all participants.  
 
        Specific aims and hypotheses:  
        To test our overarching hypothesis, we will pursue the following aims:  
        Specific Aim 1. Test the effects of single-dose vasopressin administration on laboratory-  
        based social behavior and cognitive measures in children with autism.  
        Predictions: Following single-dose vasopressin administration, participants will exhibit  
        increased accuracy in recognizing facial emotions, increased eye gaze to  
        social cues, enhanced memory for faces and names, increased social mimicry, and enhanced  
        social perceptual abilities on theory of mind tasks compared to their pre-treatment  
        performance and to the performance of placebo-treated participants.  
 
       Specific Aim 2. Test the effects of 4-week vasopressin administration using parent ratings of  
       psychosocial and behavioral functioning and laboratory-based social behavior and cognition  
       measures in children with autism. Predictions: Following 4-week vasopressin administration,  
      participants will exhibit improvements in social and behavioral functioning as assessed by  
      parent ratings on the SRS, VABS-2, ABC, RBS-R, SCAS, and PedsQL and clinician ratings  
      on the CGI compared to their performance pre-treatment and as well as compared to the  
      performance of placebo-treated participants. Following 4-week vasopressin administration,  
      participants will also show improvements on all aforementioned laboratory-based measures  
                   of social functioning compared to their performance after single-dose  
                   vasopressin administration and compared to the performance of placebo-treated participants.  
 
                Specific Aim 3. Test the tolerability of single-dose and 4-week intranasal vasopressin in  
                children with autism. Predictions: No significant differences in rates of side effects will be  
                observed between vasopressin and placebo treated groups following single-dose and 4-week  
                treatment.  
 
                Exploratory Aim 4. Test whether single-dose and/or 4-week vasopressin 


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                administration preferentially enhances social functioning in male compared to female children  
                with autism. Predictions: Vasopressin treatment will be more effective in male compared to  
                female participants consistent with evidence from preclinical studies.  
 
                Exploratory Aim 5. Test whether pre-treatment social functioning (i.e., severity of social  
                impairments as measured by pre-treatment parent SRS ratings and WSQ social subtype) and/or  
                plasma neuropeptide levels predict vasopressin treatment  
                response efficacy in children with autism.  
 
                Methods and procedures: Experimental design. Using a double-blind, randomized,                 
                placebo controlled, parallel design we will test the effects of single-dose and 4-week intranasal      
                vasopressin administration on social functioning in children with autism.  
 
                   Consent/assent will be obtained before initiating any study procedures. The primary outcome  
                   measure is change in social behavior as determined by parent ratings on the  
                   SRS after completion of the 4-week treatment trial. The SRS measures the severity     
                   of social/communication deficits as they occur in natural environments. The SRS can be used  
                   as a measure of response to intervention as well as a screening instrument.  
                   Secondary outcome measures include changes in other behavioral functioning (e.g.,  
                   communication, repetitive/disruptive behaviors, anxiety, quality of life) as measured by  
                   clinician ratings on the  CGI and as measured by parent ratings on the RBS-R,  
                   SCAS, PedsQL, VABS-2, ABC, and MSCS after completion of the 4-week treatment  
                   trial.  Secondary outcome measures also consist  
                   of laboratory-based assessments of social behavior and cognition (described below) after    
                   both single- dose and 4-week vasopressin treatment. Drug tolerability assessments, including  
                  vital signs (HR/BP and temperature), ECG, and parent report of side effects will be conducted  
                   following single- dose, 1-week, 2-weeks, 3- weeks, and 4-weeks of drug administration. BMI  
                   will be assessed after 1-week, 2-weeks, 3- weeks and 4-weeks of dosing. Clinical chemistry  
                   labs and osmolality (urine, blood) will be obtained after 1-week, 2-weeks, and 4-weeks of  
                   dosing. In cases when a blood draw cannot be obtained the urine osmolality (which is highly  
                   correlated with blood osmolality) will be able to be used as a safety measure. A similar  
                   schedule will be followed in the optional 4-week open-label extension study.  
 
                  There will be a total of up to 10 assessment time-points during this study. During the first  
                   assessment session (screening visit) participants will undergo autism diagnostic  
                   screening,  intelligence testing, medical (history and physical) and psychiatric (history)  
                   examination (incl. CGI ratings), females of childbearing age or who have started having  
                   menstrual cycles will undergo urine pregnancy testing; vital signs screening, height and   
                  weight measurement, ECG assessment, and clinical chemistry labs will be assessed.  
               
                   Participants will undergo pre-treatment assessment of behavioral and cognitive functioning  
                   in order to determine baseline levels on the various outcome measures. Parent ratings on the  
                   SRS, RBS-R, SCAS, PedsQL, VABS-2, ABC, MSCS, WSQ as well as participants’ blood  
                   samples for quantification of basal plasma vasopressin and oxytocin concentrations will be  
                   obtained.  
 
                     Laboratory measures of social behavior and cognition will be administered to facilitate in          


August 2, 2016 
 
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                     the analysis of post-treatment changes in functioning by accounting for any pre-existing  
                     individual differences. Briefly, these laboratory tasks involve assessing the ability of the  
                     participants to recognize basic emotions from images of faces presented on a computer  
                     screen. We will also record participants' eye gaze using eye- tracking technology while the  
                     participants view the emotional faces. We will determine participants’ ability  
                     to infer emotions after viewing the eye-region of facial stimuli. We will also assess 
                     participants’ memory for faces and names, and social perception abilities will be assessed  
                     using tests of theory of mind.  
 
                     On completion of the screening procedures, subjects and their parents will be instructed on  
                     administration of a placebo nasal spray and will be provided with a supply of the placebo to       
                     administer at home. This one week open- label placebo lead-in component will enhance  
                     compliance and efficacy of nasal drug delivery during the study.  
 
                 One to four weeks later, participants will return to the clinic and will be randomized in a  
                 double-blind fashion to a treatment condition (vasopressin or placebo). Stratification will be  
                 based on gender and age. Prior to drug administration, pre- treatment side effects information  
                 will be collected with the DOTES and OAS, participants will provide a blood sample for  
                 neuropeptide quantification and parent SRS ratings will be collected for a second time.  
                 Neuropeptide levels from the two blood samples and repeated parent assessment of the severity  
                 of participants’ social impairments will allow us to test for stable individual differences in   
                 these measures. Parent SRS and WSQ ratings, as well as participants’ neuropeptide levels, will  
                 allow us to test on an exploratory basis whether these baseline measures predict treatment  
                 response outcomes. Participants will then receive a single-dose of either intranasal vasopressin  
                 (12 IU or 16 IU; depending on age) or placebo and 20 minutes later will have vital signs  
                 (HR/BP and temperature) assessed prior to initiating the laboratory behavioral measures.  
                 Before participants leave the clinic they will again have their vital signs assessed (~2 hours  
                 post-dosing) and an ECG will be performed to determine cardiac functioning. Parents will be  
                 provided with instructions on the dose-escalation schedule that will occur at home and will be  
                 provided with a dosing schedule that they will be required to follow and sign off on each day.     
                 Participants will continue vasopressin or placebo administration for 4-weeks at home and their  
                 parents will be responsible for reporting any adverse events to research staff. Parents will also  
                 be informed that their children’s free water intake should be adjusted downward to decrease  
                 the potential occurrence of hyponatremia and water intoxication during the treatment period.  
 
                 Following 1- week, 2-weeks, and 3-weeks of dosing, participants are asked to return to the  
                 clinic for visits when drug tolerability will be assessed (vital signs, BMI, clinical chemistry  
                 labs (not at week-3), ECG, and parental side effects reports will be collected. On completion of  
                 the 4-week double-blind treatment period, participants will return to the clinic for assessments.  
 
                 Parent SRS, RBS-R, SCAS, PedsQL, VABS-2, ABC, and MSCS ratings and participants blood  
                 samples will be collected for neuropeptide analysis.  
 
                Participants will be tested on laboratory based social behavior and cognition tests, and  
                clinician’s impressions of treatment response will be made using the CGI. Vital signs,  
                BMI, clinical chemistry labs, osmolality (urine, blood), ECG, and parental drug side effects  


August 2, 2016 
 
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                report will also be monitored to determine drug tolerability.  
 
                 After completion of the double-blind 4-week treatment period participants will be  
                 informed of their treatment group and will have the option of participating in a 4-week open-  
                 label vasopressin treatment extension period. Participants initially randomized to placebo  
                 treatment during the randomized controlled trial will undergo vasopressin dose-escalation  
                 and safety testing in the open-label extension period in a comparative fashion to participants  
                 initially randomized to vasopressin treatment. Participants who were initially assigned to  
                 vasopressin treatment during the randomized controlled trial will have the option of  
                 continuing on their maximum tolerated dose for an additional 4- week open-label extension  
                 period. During this time participants will again undergo all previously performed safety  
                 assessments. This will provide further information regarding the tolerability of longer term  
                 vasopressin treatment (i.e., up to 8 weeks). During the open- label extension period we will  
                 conduct PK analysis to determine the Tmax of vasopressin in our study population. The  
                 timing of the blood draws during the open-label extension arm will take place at 15 minutes  
                 post- vasopressin dosing for 1/3 of the participants, at 30 minutes post-vasopressin dosing for  
                 1/3 of the participants, and at 60 minutes post-vasopressin dosing for 1/3 of the participants.  
 
                 These analyses will take place at week-5, week-6, and week-8 for all participants. Up to 30  
                 mL of blood will be collected during the blood draws mentioned above. At all of the  
                 timepoints that blood draws are mentioned above there will also be urine samples collected  
                 for urine osmolality.  
 
                  Urine and blood osmolality sample collection at Screening and Weeks 1, 2, 4, 5, 6, and 8 will  
                  be obtained. This will allow for a contingency plan in cases when blood samples are not able  
                  to be obtained at any given collection time-point since urine osmolality is highly correlated  
                  with plasma osmolality.  
 
                  On completion of the 4-week open-label treatment period, participants will return to the  
                  clinic for assessments including the parent SRS, VABS-2, ABC, RBS- R, SCAS, MSCS and  
                  PedsQL ratings. Participants will be tested on laboratory based social behavior and cognition     
                  tests, and clinician’s impressions of treatment response will be made using the CGI.  
v. 
Radioisotopes/radiation-producing machines 
N/A 
vi. 
Physical well-being 
Vasopressin and its analogs have been used for over 30 years in both pediatric and adult 
patient groups to treat central diabetes insipidus, nocturnal enuresis, and varying states of 
shock with very few serious adverse effects given simple precautions are adhered to (e.g., 
water restriction to prevent hyponatremia and water intoxication). See above for a 
comprehensive discussion of potential risks associated with vasopressin administration. 
Obtaining blood can cause bruising and can hurt briefly which applying a topical 
anesthetic can minimize. 
vii. 
Psychological well-being 


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Page 27 of 33 
There are minimal risks to individuals from interviewing, testing measures, and blood 
draws other than loss of time at school and parental work. The risks associated with the 
testing measures are minimal and are limited to performance anxiety or fatigue. There 
will be an attempt to schedule appointments for assessments at times that minimize loss 
of time from the child's school schedule and caregiver's work. Parents may experience 
some discomfort in responding to questions asked during the initial interview or to items 
on the various measures. Blood collection can also cause stress and anxiety for some 
individuals. Blood collection will occur at the Lucile Packard Children’s Hospital 
(LPCH) Phlebotomy Clinic by trained pediatric phlebotomists, who have extensive 
experience working with children on the autism spectrum.  
 
Research on vasopressin and aggression in rodents has generally shown that vasopressin 
increases aggression in: 1) non-monogamous adult male residents when an adult male 
intruder is introduced into his “territory” (i.e., home cage), and 2) monogamous adult 
male residents when an adult male intruder is introduced into his territory, which 
sometimes includes the mate and pups.1,2 It is arguable that increased aggression in these 
behavioral assays is adaptive, and in the context of the latter example, increased 
aggression in the presence of mate/pups in the home territory is a protective response that 
is prosocial in nature, at least with regard to the resident male’s family. Nevertheless, we 
acknowledge that monitoring aggression in children in our pilot treatment trial is an 
important precaution. Therefore, we will regularly inquire about aggressive behavior 
throughout the study.  
viii. 
Economic well-being 
Low to almost no risk. 
ix. 
Social well-being 
Low to almost no risk. 
x. 
Overall evaluation of risk 
Low risk. 
b. 
International Research Risk Procedures 
N/A 
c. 
Procedures to Minimize Risk 
Every precaution will be taken to use the safest and most gentle procedures possible.  
 
Cognitive and behavioral assessments and paper-and-pencil tests: The risk of the 
cognitive and behavioral tests are minimal and are limited to performance anxiety or 
fatigue. To minimize these problems, testing will not begin until the participant is 
comfortable with the testing environment and the tester. Staff with experience working 
with children with disabilities will administer the tests, provide breaks as needed, and 
adjust the length of the test sessions to each individual. Participants will be provided with 
frequent positive feedback and will receive certificates in recognition of their 
participation. Each examiner will be attentive to participant fatigue and provide breaks 


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accordingly. Parents/legal guardians may experience discomfort in revealing personal 
information regarding psychiatric and medical status; hence, we will provide support and 
assure that personal information is kept in a locked cabinet with no personal identifiers on 
the forms except for a participant ID number.  
 
Scheduling during school/caregiver work: There will be an attempt to schedule 
appointments for research assessments at times that minimize absence of the child from 
school and the caregiver from work.  
 
Blood draws: Obtaining blood can hurt briefly and can cause bruising; this will be 
minimized by applying a topical anesthetic and by having experienced staff draw 
children’s blood samples. All Lucile Packard Children’s Hospital laboratory staff have 
considerable experience working with children. The phlebotomists are trained to work 
with youth of a wide age range and different neuropsychiatric disorders, including 
autism.  
 
AVP-side effects: As discussed above, the use of IN AVP in several research studies has 
been associated with limited side effects. However, in light of the young age of 
participants, the lack of experience with IN AVP in individuals with autism, and the 
theoretical pharmacological effects, a series of protective measures will be applied to 
minimize risk, and increase monitoring. Briefly (see above for full list):  
1. Vital signs (HR/BP, temperature) monitoring will be conducted before and after (20 
minutes, 2 hours) initial single dose AVP administration, and following 1, 2, 3 and 4 
weeks of dosing.  
2. BMI will be measured at screening, and following 1-week, 2-weeks, 3-weeks and 4 
weeks of dosing.  
3. DOTES side effects report and OAS will be collected prior to initiation of dosing and 
on completion of 1, 2, 3 and 4 weeks of dosing.  
4. ECG monitoring will be conducted at screening and after completion of single-dose, 1, 
2, 3 and 4 weeks of dosing.  
5. Clinical chemistry labs will be conducted at screening and following 1-week. 2-weeks, 
and 4-weeks of dosing.  
6. A study investigator will be available 24 hours a day to respond to adverse events.  
7. Participants and their families will be briefed on procedures for responding to potential 
adverse events (see Procedures for Handling Adverse Events section below).  
 
All safety procedures will be repeated during the optional open-label extension period.  
 
Procedures for Handling Adverse Events:  
Single-dose (initial administration): If, following the initial dosing, body temperature 
changes more than 2°F, heart rate changes more than 20 bpm, blood pressure changes 
more than 20%, or any signs of adverse reactions to the drug are noted (e.g., listlessness, 
vomiting, seizure activity) then close monitoring will occur and the participant will be 
assessed by the study physician. If indicated, participants will be immediately escorted to 
the Lucile Packard Children’s Hospital (LPCH) Emergency Room, for treatment and 
their participation in the study will be terminated. The LPCH Emergency Room is within 
a short distance from the Stanford University Psychiatry and Behavioral Sciences 


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building (~2 blocks), where initial dosing will occur. LPCH is a state-of-the-art hospital 
outfitted with the most advanced medical equipment. The hospital employs qualified staff 
to handle any type of medical emergency in children and adolescents.  
 
Outpatient dosing phase: For any adverse events, families will be instructed to contact the 
research coordinator at 650-736-1235 during business hours, and through the Stanford 
page operator after hours and during weekends/holidays. (A project coordinator will be 
available 24/7 to respond to safety concerns.) If the adverse event is life threatening, 
participants will be asked to call 911 or referred to the nearest emergency room. If the 
adverse event is not life threatening, the study coordinator will contact the study 
physician who will contact the family directly and inquire about the adverse event. If the 
study physician judges the side effects as minor or benign, a decision will be made 
whether or not the participant will continue in the study. If side effects are judged as 
severe and might be related to AVP, the participants will be asked to stop the study drug 
immediately and will be invited to come in to the clinic within 24 hours for a direct 
evaluation and termination of their participation in the study. If the study physician feels 
that the adverse event requires immediate medical attention, parents will be instructed to 
contact 911 or go to the nearest emergency room. The study physician will also have the 
ability to break the blind if it is felt that doing so is in the best interest of the participants’ 
health.  
 
Any serious adverse events will be reported to the Data and Safety Monitoring Board 
(DSMB) and Stanford Institutional Review Board (IRB) within 24 hours and to the Food 
and Drug Administration (FDA) within seven calendar days.  
 
Data safety and monitoring board: A DSMB will be established to monitor the proposed 
clinical trial that will be registered with, and will receive approval from, the FDA as an 
Investigation New Drug. (This study will also be listed on clinicaltrials.gov and on 
Stanford University’s Clinical Trials Directory.) The DSMB will include several 
physicians who are not involved in the research investigations. The DSMB will meet on a 
quarterly basis to assess data quality and timeliness, participant recruitment, accrual and 
retention, participant risk-versus-benefit (including review of all adverse reactions and 
SAEs), and any breaches of confidentiality. Reports will be submitted to the Stanford 
University IRB on a quarterly basis, as part of the annual IRB review process, as well as 
for the annual report. We will also submit annual reports to the FDA.  
 
Confidentiality: All information from the evaluation and assessment of all participants 
are subject to standard confidentiality procedures followed at Stanford as mandated by 
the IRB. Information will not be released to any party, except with the written consent of 
the participant and his/her parents/legal guardians. Participants’ identity will be 
concealed in data records and files by use of assigned ID codes. Research data will be 
maintained in locked storage cabinets in a locked file room. Only project staff will be 
allowed in this room. The screening, diagnostic, and neuropsychological tests are 
maintained in folders for each participant, stored in locked cabinets, in locked rooms, 
within a locked suite. When the data are transferred to data summary sheets, only the 
participant number appears on the sheet and it alone is entered into the database.  
We will continuously monitor both our procedures and our data to be sure we are in 


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compliance with confidentiality guidelines. Research staff members are carefully trained 
about the critical nature of participants’ confidentiality and about the procedures for 
respecting and maintaining it. They are instructed to file data immediately after they have 
been collected, never to leave unlocked or opened data files unattended, never to discuss 
participants’ behavior outside of the research study, and never to mention the name(s) of 
participants except to other research staff on this project. They are also instructed on the 
procedures for assigning ID numbers and for filing data separately from participant-
identification information. All staff members complete training modules on human 
subjects’ protection and take an examination to obtain certification.  
 
Data and safety monitoring by PIs: Drs. Parker and Hardan will oversee all data and 
safety monitoring. They will hold weekly meetings with staff to discuss progress of the 
research study (data quality, timeliness, and participant recruitment), outcome and 
adverse event data and changes to the benefit-to-risk ratio that would change the design 
of the experiment, and issues related to confidentiality ensuring that procedures for 
obtaining information in a private manner were performed and that documentation was 
stored in the appropriate locked file cabinets. The PIs will also hold separate monthly 
educational meetings to discuss any new information relevant to this study. They will be 
responsible for reporting any serious and unexpected adverse reactions to the IRB and 
DSMB within 24 hours and to the FDA within seven calendar days. Any identifying 
information collected from participants in this study will be kept strictly confidential. As 
mentioned above, the participants will be assigned an exclusive ID code for all data, and 
all information in research files will be coded using that number rather than the 
participant’s name. A name log will be kept in a locked desk in a locked office at all 
times. All data will be entered onto a secured database. Scientifically trained and properly 
authorized employees of the FDA and/or Stanford University may inspect the relevant 
records. We are committed to complying with FDA and IRB policies for reporting 
serious and unexpected adverse events.  
 
For maximal benefit to the field, de-identified data will be made available to other 
investigators through the National Database for Autism Research (NDAR) and related 
information will be included in our consent form. 
d. 
Study Conclusion 
Single-dose (initial administration): If, following the initial dosing, body temperature 
changes more than 2°F, heart rate changes more than 20 bpm, blood pressure changes 
more than 20%, or any signs of adverse reactions to the drug are noted (e.g., listlessness, 
vomiting, seizure activity) then close monitoring will occur and the participant will be 
assessed by the study physician. If indicated, participants will be immediately escorted to 
the Lucile Packard Children’s Hospital (LPCH) Emergency Room, for treatment and 
their participation in the study will be terminated. The LPCH Emergency Room is within 
a short distance from the Stanford University Psychiatry and Behavioral Sciences 
building (~2 blocks), where initial dosing will occur. LPCH is a state-of-the-art hospital 
outfitted with the most advanced medical equipment. The hospital employs qualified staff 
to handle any type of medical emergency in children and adolescents.  
 
Outpatient dosing phase: For any adverse events, families will be instructed to contact the 


August 2, 2016 
 
Page 31 of 33 
research coordinator at 650-736-1235 during business hours, and through the Stanford 
page operator after hours and during weekends/holidays. (A project coordinator will be 
available 24/7 to respond to safety concerns.) If the adverse event is life threatening, 
participants will be asked to call 911 or referred to the nearest emergency room. If the 
adverse event is not life threatening, the study coordinator will contact the study 
physician who will contact the family directly and inquire about the adverse event. If the 
study physician judges the side effects as minor or benign, a decision will be made 
whether or not the participant will continue in the study. If side effects are judged as 
severe and might be related to AVP, the participants will be asked to stop the study drug 
immediately and will be invited to come in to the clinic within 24 hours for a direct 
evaluation and termination of their participation in the study. If the study physician feels 
that the adverse event requires immediate medical attention, parents will be instructed to 
contact 911 or go to the nearest emergency room. The study physician will also have the 
ability to break the blind if it is felt that doing so is in the best interest of the participants’ 
health.  
 
Any serious adverse events will be reported to the Data and Safety Monitoring Board 
(DSMB) and Stanford Institutional Review Board (IRB) within 24 hours and to the Food 
and Drug Administration (FDA) within seven calendar days. 
e. 
Data Safety Monitoring Plan (DSMC) 
i. 
Data and/or events subject to review 
1. Vital signs (HR/BP, temperature) monitoring will be conducted before and after 
(20 minutes, ~2 hours) initial single dose administration, and following 1, 2, 3, and 4 
weeks of dosing as well as weekly during the optional open-label extension.  
2. BMI will be measured at screening, and following 1, 2, 3, and 4 weeks of dosing.  
3. DOTES side effects report and OAS will be conducted prior to initiation of dosing 
and on completion of 1, 2, 3 and 4 weeks of dosing.  
4. ECG monitoring will be conducted at screening and following single-dose, 1, 2, 3 
and 4-weeks of dosing.  
5. Clinical chemistry labs will be conducted at screening and following 1, 2, and 4-
weeks of dosing.  
 
All safety assessments outlined above will be repeated during the optional open-label 
extension period. 
ii. 
Person(s) responsible for Data and Safety Monitoring 
A DSMB will be established to monitor the proposed clinical trial that will be 
registered with, and will receive approval from, the FDA as an Investigation New 
Drug. (This study will also be listed on clinicaltrials.gov and on Stanford 
University’s Clinical Trials Directory.) The DSMB will include several physicians 
who are not involved in the research investigations The DSMB will meet on a 
quarterly basis to assess data quality and timeliness, participant recruitment, accrual 
and retention, participant risk-versus-benefit (including review of all adverse 
reactions and Serious Adverse Events [SAEs]), and any breaches of confidentiality. 
Reports will be submitted to the Stanford University IRB on a quarterly basis, as part 


August 2, 2016 
 
Page 32 of 33 
of the annual IRB review process, as well as for the annual report. We will also 
submit annual reports to the FDA. 
iii. 
Frequency of DSMB meetings 
The data and safety monitoring committee will meet on a quarterly basis to assess 
data quality and timeliness, participant recruitment, accrual and retention, participant 
risk versus benefit (including review of all adverse reactions and SAEs), and any 
breaches of confidentiality. Reports will be submitted to the Stanford University IRB 
on a quarterly basis, as part of the annual IRB review process, as well as for the 
annual report. We will also submit an annual report to the FDA. 
iv. 
Specific triggers or stopping rules 
A serious adverse event or reaction is any untoward medical occurrence that at any 
dose: results in death, is life-threatening, requires inpatient hospitalization, results in 
persistent or significant disability/incapacity, an important medical event (defined as 
a medical event(s) that may not be immediately life-threatening or result in death or 
hospitalization but, based upon appropriate medical and scientific judgment, may 
jeopardize the patient/subject or may require intervention (e.g., medical, surgical) to 
prevent one of the other serious outcomes. Cancer/Overdose: All cases of cancer and 
overdose will be reported immediately.  
v. 
DSMB Reporting 
Any serious adverse events will be reported to the DSMB and Stanford IRB within 
24 hours and to the FDA within seven calendar days. 
vi. 
Will the Protocol Director be the only monitoring entity? (Y/N) 
No 
vii. 
Will a board, committee, or safety monitor be responsible for study monitoring? 
(Y/N) 
Yes 
f. 
Risks to Special Populations 
Research involving greater than minimal risk but presenting the prospect of direct benefit to the 
individual subjects. The research presents more than minimal risk to children, but holds out the 
prospect of direct benefit for the individual subject or is likely to contribute to the subject's well-
being. Please provide rationale that: (a) the risk is justified by the anticipated benefit to the 
subjects; (b) the relation of the anticipated benefit to the risk is at least as favorable to the subjects 
as that presented by available alternative approaches; and (c) adequate provisions are made for 
soliciting the assent of the children and permission of their parents or guardians. 
10. 
BENEFITS 
 
               As of now, there is no effective intervention strategy aimed at targeting the core symptoms of  
               autism and curbing the long course and guarded prognosis of autism. Outcome studies indicate     
               that about 2/3 of autistic adults remain severely handicapped and live in complete dependence or  


August 2, 2016 
 
Page 33 of 33 
               semi-dependence. Available agents aim at controlling associated behavioral features such as  
               aggression, agitation and compulsive behaviors. Agents that treat underlying chronic  
               neurobiological abnormalities are lacking. The suggested innovative agent (vasopressin), if  
               shown to be effective, will lead to the development of new strategies to treat individuals with  
               autism spectrum disorders. 
 
11. 
PRIVACY AND CONFIDENTIALITY 
All participant information and specimens are handled in compliance with the Health Insurance 
Portability and Accountability Act (HIPAA) and privacy policies of Stanford University, Stanford 
Health Care, and Stanford Children’s Health. 

SAP_000.pdf: 
The Role of Vasopressin in the Social Deficits of Autism 
 
NCT01962870 
 
January 11, 2019 
Antonio Hardan, MD, Principal Investigator 
Karen Parker, PhD, Principal Investigator 
Stanford University 
Stanford, California 94305 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Statistical Analysis Plan 
 
Data will be managed using REDCap and analyzed using Least-Squares General Linear 
Models (LS-GLMs) in JMP Pro 13 and SAS 9.4 for Windows (SAS Institute Inc., Cary, NC). 
Efficacy analyses will be guided by our pre-study aims which included: 1) testing for treatment 
main effects on the primary and secondary outcome measures; and 2) testing whether 
pretreatment blood-based biological measures predicted who benefited from treatment. To 
minimize the risk of false discovery, we will first identify a robust model using our primary 
outcome measure (i.e., change in the SRS-2 T-Score), and then apply that model to all other 
outcomes. P<0.05 will be considered significant and two-tailed tests will be used throughout. 
Post-hoc tests will be Bonferroni corrected to maintain a family level of P<0.05 (as detailed 
below).  
 
The initial model will included sex, ethnicity, weight, IQ, and blood collection time as blocking 
(control) factors. Pretreatment SRS-2 T-Score will be included as a blocking factor to account for 
the range of possible improvement, and thus reduce possible floor or ceiling effects. Finally, we 
will include treatment condition (i.e., AVP or Placebo) to test our main hypothesis, and 
pretreatment blood AVP concentration and pretreatment blood neuropeptide receptor gene 
expression (expressed as an AVPR1A-to-OXTR ratio to account for within-individual 
differences in expression) as measures of endogenous AVP function that might predict treatment 
efficacy. As we administered two different AVP doses according to age, dose will be nested 
within treatment condition to explicitly test for an overall effect of AVP treatment, and 
secondarily to control for any dose-related effects. We will also test for treatment 
condition×biological measure and dose×biological measure interactions, as pretreatment 
biological measures should generally only predict treatment outcome in the drug-treated 
individuals. Finally, because the SRS is a parent reported measure, we will collect SRS scores at 
two pretreatment time points to identify the reliability of an individual participant’s scores. This 
will enable us to use Weighted Least-Squares General Linear Model (WLS-GLM) analyses 
whenever parent-reported measures are assessed. WLS ideally uses the inverse of the variance of 
a mean estimate as the weight, which we will be able to obtain directly from our two 
pretreatment SRS scores. 
  
Non-significant interactions will be removed in order to avoid confounds of marginality for the 
main effects, and to distinguish blocking factors. We will tested dose nested within treatment 
condition and pretreatment blood AVP concentration as main effects, and the interaction of 
pretreatment blood AVP concentration with dose-nested-within-treatment condition. Thus, the 
model will contain the biologically and experimentally essential variables, regardless of 
significance. We will further test the robustness of this model by confirming that key results will 
be held when different blocking factors are included or excluded and if WLS-GLM is not 
employed. Effect sizes will be calculated as ηp2 (partial eta-squared), as appropriate for complex 
linear models. Equivalent Cohen’s d will be provided for main effects where justifiable. The 
same model will be applied to all secondary outcome measures with the exception that the 
baseline, pretreatment behavioral measure will be replaced to match the outcome variable. For 
child performance measures, LS-GLM, not WLS-GLM, will be used. For CGI-I, in which there 
is no baseline pretreatment measure, the model will not include a baseline control. Effect sizes 
for these secondary outcome 


measures will likewise be calculated as ηp2. 
 
To minimize the risk of false discovery from multiplicity, we will first test the total score 
for each instrument, and then only test subscales if the total scores are significant. Subscales 
will be Bonferroni-corrected for multiple comparisons. The assumptions of WLS-GLM 
(linearity, homogeneity of variance, and normality of error) will be confirmed post-hoc and 
suitable transformations will be applied as needed. Post-hoc tests will be performed as planned 
contrasts and further Bonferroni-corrected for multiple comparisons. We will test 
our first aim by testing for an overall effect of treatment condition at the mean pretreatment 
blood AVP concentration. 
 
Fisher’s exact Test will be used to test for differences between treatment conditions for 
participant characteristics and concomitant medications. χ2 Likelihood Ratio will be used to test 
whether parents are able to accurately ascertain the treatment condition to which their child has 
been randomized. Pearson’s correlation coefficient will be used to test the relationship between 
change from baseline in parent-reported SRS T-Score and clinician evaluated CGI-I Score in 
AVP treated participants. One-way LS-GLMs will be used to test the change from baseline 
between the AVP and Placebo treatment groups following 4-week treatment for adverse events 
and safety measures, as well as to test the difference in post-treatment bottle weights between 
treatment conditions. Suitable transformations will be applied as needed.