Conditions: 22q13 Deletion Syndrome Phelan-McDermid Syndrome
Keywords: SHANK3 IGF-1 Autism
Allocation: RANDOMIZED | Intervention model: CROSSOVER
Enrollment: 19
Healthy volunteers: no

Brief summary:
The purpose of this study is to pilot the use of Insulin-Like Growth Factor-1 (IGF-1) treatment in 22q13 Deletion Syndrome (Phelan-McDermid Syndrome) caused by SHANK3 gene deficiency in order to evaluate safety, tolerability, and efficacy. IGF-1 is an injection under the skin that contains human IGF-1. IGF-1 is approved by the FDA under the brand name Increlex for the treatment of children with short stature due to primary IGF-1 deficiency. It is being used off-label in the current study and is not FDA approved, nor has it yet been studied in humans for the treatment of SHANK3 deficiency.

Detailed description:
Overall, there will be 1-3 screening visits, a baseline visit where study drug will first be administered, and then 10 follow-up visits. Follow-up visits will occur at week 2, week 4, week 8, and week 12 in each treatment phase (IGF-1 or placebo), and then again 4 weeks after study completion, Parents/guardians will be asked to administer the IGF-1/ placebo by injection at home and will also be responsible for monitoring glucose levels in the child. Parents/guardians will be trained in these methods, and will have scheduled phone calls and appointments where the dose and tolerability will be discussed.

Assessments include the following:

* Physical and neurological examination
* Medical and psychiatric history
* X-ray of long bone (e.g., hand) to ensure your child's growth plates are not closed
* Electrocardiography
* Echocardiography
* Pregnancy test if applicable
* Lab safety measures (through blood draw)
* Autism Diagnostic Interview (ADI)
* Autism Diagnostic Observation Schedule (ADOS)
* The Mullen Scales of Early Learning or the Leiter International Performance Scale-Revised
* Vineland Adaptive Behavior Scale (VABS)
* Clinical Global Impressions (CGI) Rating Scales
* The Repetitive Behaviors Scale (RBS)
* Aberrant Behavior Checklist (ABC)
* The Caregiver Strain Questionnaire (CSI)
* Language Environment Analysis (LENA)
* The Macarthur-Bates Communication Inventory (MCDI)
* Unified Parkinson's Disease Rating Scale (UPDRS)
* Quick Neurological Screening Test 2nd Edition (QNST-2)
* Gait Analysis with motion capture video systems and interactive 3-dimensional modeling systems

Arms:
arm 1: Injection arm 2: Injection

Interventions: intervention 1: Insulin-Like Growth Factor-1 (IGF-1) intervention 2: Normal saline
Intervention descriptions: intervention 1: IGF-1 and placebo will each be administered for 3 months with a four-week washout period in between. IGF-1 will be administered for 3 months subcutaneously. intervention 2: Saline solution will be administered for three months subcutaneously.

Protocol document:
Prot_SAP_000.pdf: 
A Double-Blind Placebo-Controlled Crossover Trial of Insulin-Like Growth Factor-1 
(IGF-1) in Children and Adolescents With 22q13 Deletion Syndrome(Phelan-
McDermid Syndrome)  
PI: Dr. Alexander Kolevzon
NCT01525901
Document Date: 1/1/2013


RESEARCH STRATEGY 
Significance. Several of the ASD genes identified to date, including SHANK3, are involved in the 
neuroligin-neurexin pathway at glutamatergic synapses (Bonaglia et al, 2011; Durand et al., 2007; Gauthier et 
al., 2009; Guilmatre et al., 2009; Moessner et al., 2007; Rosenfeld et al., 2010; Schaaf et al., 2011; Sebat et 
al., 2007). Glutamate signaling is also highly relevant to these pathways and to various forms of ASD. SHANK3 
is a protein found in glutamatergic synapses that helps form the postsynaptic density, and upon which 
glutamate receptors are clustered (Sheng and Kim 2000; Boeckers 2006; Kreienkamp 2008). There is now 
abundant evidence that SHANK3 is a key regulator of synapse development and function and a critical protein 
for many synaptic processes. Most importantly, large-scale analyses show that SHANK3 and associated 
pathways are implicated in multiple forms of ASD, including tuberous sclerosis and Fragile X syndrome (FXS) 
(Darnell et al., 2011; Sakai et al., 2011). According to the Interagency Autism Coordinating Committee 2011 
Strategic Plan, there is a need for translational research that takes advantage of genetic findings in order to: 1) 
develop animal models to understand the effects of these genetic variants on brain function, 2) inform which 
molecular signaling pathways are affected in ASD, and 3) discover specific targets for the development of 
novel therapeutics. Following this approach, our group developed Shank3-deficient mice and discovered that 
AMPA-receptor signaling and long-term potentiation (LTP) were impaired, with no significant change in long-
term depression (LTD) (Bozdagi et al., 2010). Treatment with IGF-1 was then tested and found to reverse the 
electrophysiological and behavioral deficits in Shank3 heterozygous mice (see Figure 1). The SHANK3 / 
glutamate signaling pathway is highly relevant to various forms of ASD; the link between deficits in synapse 
function and ASD suggest that treatment with IGF-1 may have implications for ASD associated with disruptions 
in common underlying pathways, and this is supported by ongoing studies of IGF-1 in Rett syndrome. This 
contribution will be significant because we aim to pilot a potentially disease-modifying treatment which has the 
potential to shed light on pathways more broadly relevant to ASD treatment. 
Innovation. To date, the development of pharmacological treatments in ASD has mainly relied on 
strategies only loosely related to what is known about the neurobiology of the disorders, using etiologically 
heterogeneous samples, and delivering intervention broadly with mixed success. More recently, genetic 
discovery and model systems have led to important opportunities for developing novel, disease-modifying 
therapeutics. The proposed project represents a unique effort between clinical and basic science resources 
and draws upon the experience of clinicians with recognized expertise in SHANK3 deficiency and ASD. This 
work is based on preclinical evidence that establishes proof-of-concept with IGF-1 reversing 
electrophysiological deficits in Shank3-deficient mice. A recent example of a similar approach is the large-scale 
clinical trial with arbaclofen currently underway in Fragile X syndrome (FXS) and in ASD. FXS accounts for 
approximately 1-2% of ASD cases and detailed analysis of mouse and other models of FXS gave rise to a 
hypothesis that the metabotropic glutamate receptor in the synapse represents a potential target in the 
disorder. Drugs that targeted this receptor were tried in mice and other model organisms that had mutations 
that mimic FXS (Bear et al., 2004; Yan et al., 2005). These drugs were shown to correct some of the cellular 
and behavioral deficits observed in the mice and are now being studied in human trials. Trials using 
comparable strategies of discovery are likewise underway in Rett syndrome and tuberous sclerosis, both 
known causes of ASD. The proposed project is innovative, in our opinion, because it is based on the 
combination of a previously tested drug development strategy, convincing preclinical evidence with IGF-1 in a 
mouse model system, and a safe approved drug. In addition, it is innovative in that we introduce objective 
measures of language and social attention in the context of experimental therapeutics.  
Approach. 
Aim: Evaluate safety, tolerability, and feasibility of IGF-1 vs. placebo targeting social withdrawal 
using the ABC-SW subscale as a primary outcome measure and additional secondary and exploratory 
outcome measures including objective assessments of language and social attention. 
Introduction. The objective of this aim is to pilot the use of IGF-1 treatment in 18 patients with 
SHANK3 deficiency in order to evaluate safety, tolerability, and feasibility for a core deficit of ASD – social 
impairment. We will approach this aim by employing a placebo-controlled, double-blind, crossover design with 
three months of treatment with IGF-1 and three months of placebo in random order, separated by a four week 
wash-out period. The rationale is that successful completion of the proposed research will establish feasibility 
and contribute pilot data from the first treatment trial of SHANK3 deficiency to the field. It will also advance 
knowledge about developing targeted treatments for additional causes of ASD associated with impaired 
synaptic development and function. It is our expectation, based on our rodent model, that the knowledge 
gained provide evidence for a novel therapeutic that has specific and disease-modifying effects on ASD 


associated with SHANK3 deficiency and pave the way for more trials in other subtypes of ASD with disruptions 
in shared pathways. We expect to add significantly to data from ongoing trials with IGF-1 in Rett syndrome and 
will be collaborating closely with the PI, Dr. Walter Kaufmann (see Letter of Support), on dosing and safety.  
Justification and feasibility. There have been no controlled treatment trials in SHANK3 deficiency to 
date. Our clinical experience comprehensively evaluating 32 affected families provides numerous anecdotal 
reports of medication trials that borrow from the broader ASD literature and target associated symptoms of 
attention deficit, impulsivity, hyperactivity, irritability, and repetitive behavior. An exhaustive literature review 
revealed only two published reports of medication treatment in SHANK3 deficiency, one case series with 
intranasal insulin (Schmidt et al., 2008) and one case study with risperidone (Pasini et al., 2009), both with 
reported improvement. In the intranasal insulin study, six children received up to 12 months of treatment with 
“extremely positive development” based on sum of scores from a parental questionnaire in most domains, 
including cognitive, speech and language, and motor skills (Schmidt et al., 2009). Insulin was hypothesized in 
these cases to improve neuronal function by increasing central nervous system (CNS) glucose uptake and 
enhance synaptic plasticity via glutamatergic receptors. Results from the case study with risperidone were 
similarly optimistic but equally uncontrolled: an 18 year old girl with SHANK3 deficiency was treated with 
risperidone 0.5 mg BID with significant improvement on the Clinical Global Impression Scale (CGI; Guy 1976) 
in anxiety, aggression, and insomnia after one month that was sustained after six months. The hypothesized 
mechanism of action of risperidone in SHANK3 deficiency was to promote NMDA transmission via dopamine 2 
receptor blockade. Our studies, however, indicate that reduced basal neurotransmission of Shank3-deficient 
mice at glutamatergic synapses may be AMPA receptor-mediated (Bozdagi et al., 2010).   
Results from treatment with recombinant human (rh) IGF-1 in our Shank3-deficient mouse model are 
extremely intriguing (see Preliminary Studies). Importantly, IGF-1 has also been explored in Rett syndrome, 
another monogenic cause of ASD. Rett syndrome is caused by mutations in the genes coding for methyl CpG-
binding protein 2 (MeCP2) and Tropea and colleagues (2009) used mice deficient in MeCP2 to show that 
treatment with N-terminal peptide IGF-1 reverses some of the phenotype, including extending lifespan, 
improving locomotion, improving respiration, and decreasing heart rate irregularities, all deficits found in both 
humans and mice with the condition. MeCP2 mutant mice have also been shown to have profound reductions 
in synaptic activity in slices of sensorimotor cortex (Chao et al., 2007; Dani et al., 2005), and this reduction was 
partially but significantly reversed by IGF-1 peptide (Tropea et al., 2009). In addition, Marchetto and colleagues 
(2010) developed induced pluripotent stem cells (iPSCs) from Rett patients‟ fibroblasts and found that derived 
neurons had fewer glutamatergic synapses, a phenotype that was rescued with rhIGF-1. 
IGF-1 enters the brain from the circulation where it is released mainly by the liver upon growth hormone 
stimulation. Blood-borne IGF-1 is found in the CNS where it promotes brain vessel growth (Lopez-Lopez et al., 
2004), neurogenesis, and synaptogenesis (O‟Kusky et al., 2000). The mechanisms that trigger IGF-1 entry 
through the BBB are proposed to occur by diffusible messengers and depend on neuronal activity, which 
regulates neurovascular coupling and BBB permeability (Nishijima et al., 2010). These messengers stimulate 
matrix metalloproteinase-9 (MMP9) and lead to cleavage of the IGF binding protein-3 (IGFBP-3). Cleavage of 
IGFBP-3 increases free IGF-1 and allows passage of circulating IGF-1 into the CNS through an interaction with 
the endothelial transporter lipoprotein-related receptor 1 (LRP1) (Nishijima et al., 2010).  
Preliminary Studies. Our group studied mice with a targeted disruption of Shank3, in which exons 
coding for the ankyrin repeat domain (ARD) were deleted and expression of full-length Shank3 was disrupted 
(note that a point mutation in the ARD has been described in a child with autism, Moessner et al., 2007). We 
examined synaptic transmission and plasticity by multiple methods and results indicate a reduction in basal 
neurotransmission in SHANK3 heterozygous mice (Bozdagi et al., 2010). Studies with a specific AMPA 
receptor antagonist and NMDA receptor antagonist demonstrated that the decrease in basal transmission 
reflected reduced AMPA receptor-mediated transmission. LTP was impaired in SHANK3 heterozygous mice, 
with no significant change in LTD (Bozdagi et al., 2010 and Figure 1). In concordance with the LTP results, 
persistent expansion of spines was observed in control mice after theta burst pairing-induced LTP; however, 
only transient spine expansion was observed in SHANK3 heterozygous mice. Behaviorally, male SHANK3 
heterozygotes also displayed less social sniffing and emitted fewer ultrasonic vocalizations during interactions 
with estrus female mice, as compared to wildtype littermate controls (Bozdagi et al., 2010). 
Based on our hypothesis that reduced AMPA receptor levels reflected less mature synapses, and the 
emerging story with IGF-1 in Rett syndrome, we examined whether IGF-1 treatment could reverse deficits in 
Shank3-deficient mice. Our data show that intraperitoneal injection of IGF-1 at 240 µg/kg/day for 2 weeks 
reverses the electrophysiological deficits seen in the Shank3 heterozygous mice (Figure 1). Shank3 


heterozygotes no longer demonstrated reduced AMPA receptor-mediated transmission and showed normal 
LTP like that seen in wildtype animals (Bozdagi et al., unpublished and Figure 1).  
Figure 1. Reversal of electrophysiological deficits in Shank3-deficient mice (Het) as compared to wildtype mice 
(WT) after treatment with recombinant human IGF-1 (rhIGF1) 
240 µg/kg/day was selected because 
it represents the maximum dose according 
to the current FDA label. This finding 
informs our dose titration schedule and 
supports the approach to titrate to 120 µg/kg 
twice daily (240 µg/kg/day) as rapidly as 
safety and tolerability allows. If positive 
effects 
are 
seen, 
future 
studies 
will 
determine the minimal effective dose.  
In additional preliminary studies, 
male wildtype and Shank3 heterozygous 
mice were treated with saline or 
recombinant human IGF-1 and tested for 
motor performance and motor learning by 
measuring time latencies to fall off a rotating 
rod. Mice were challenged with three 2-
minute trials (each separated by 15 minutes) 
where the rotation was gradually increased from 0 to 45 rpm. Heterozygous mice injected with saline exhibited 
reduced latencies (time) to fall off as compared to wildtype mice (p=0.017). After IGF-1 treatment, 
heterozygous mice exhibited significantly longer latencies in comparison to saline-injected mice of the same 
genotype (p=0.003) (Bozdagi et al., unpublished).  
In addition, our clinical group has evaluated 32 patients with SHANK3 deficiency using a 
comprehensive assessment battery. Eighty-three percent of these patients meet criteria for ASD using gold 
standard instruments, including the Autism Diagnostic Interview-Revised (ADI-R; Lord et al., 1994), the Autism 
Diagnostic Observation Schedule-Generic (ADOS-G; Lord et al., 2000), and the Diagnostic and Statistical 
Manual for Mental Disorders-IV (DSM-IV; APA, 1994).Ninety-seven percent of patients had intellectual 
disability and 50 percent were profoundly intellectually disabled. Three patients have already been enrolled in a 
clinical trial with IGF-1 using the proposed design to begin collecting data on the safety, tolerability, and 
feasibility of IGF-1 vs. placebo targeting social withdrawal and additional secondary and exploratory outcome 
measures. Although it is too soon to evaluate efficacy, there have been no significant adverse events.  
In an ongoing clinical trial in humans with Rett syndrome previously conducted at Boston Children‟s 
Hospital by Dr. Omar Khwaja and now assumed by Dr. Walter Kaufmann (see letter of support), 12 patients 
have completed a four-week safety study with IGF-1 and 24 patients are in ongoing treatment. Dr. Kaufmann 
will serve as a consultant on this project. Among the 12 treated girls with Rett syndrome who completed four 
weeks of treatment, there were no serious adverse events (AEs) related to IGF-1. Two AEs were determined 
not related to IGF-1 and one AE was determined possibly related to IGF-1: gingival hyperplasia in a patient 
also on phenytoin. Dr. Kaufmann‟s safety protocol uses a dose escalation design beginning at 0.04 mg/kg BID 
and titrating to 0.12 mg/kg BID in week three and four. A positive signal is found with IGF-1 in Rett syndrome at 
0.12 mg/kg BID within four weeks (Kaufmann, personal communication).  
Research design. Treatment will follow a randomized, placebo-
controlled, crossover format with 12 weeks in each treatment arm (IGF-1 
and placebo), separated by a four-week wash-out phase. The trial 
duration was selected based on preliminary evidence with IGF-1 in Rett 
syndrome and our primary outcome, the ABC, is sensitive to change 
within this time frame (Aman, 2010).  
Inclusion criteria: The proposed pilot will recruit 18 children between 5 and 12 years-old with SHANK3 
deficiency previously evaluated as part of ongoing studies in our Center. All subjects will have a minimum raw 
score of 12 on the ABC-SW based on the decision to use this scale as the primary outcome measure (see 
Outcome Measures section). The minimum raw score was selected by adding approximately one standard 
deviation to the mean ABC-SW subscale score derived from a normative sample of 601 children aged 6-17 
with intellectual disability (Brown et al., 2003). Subjects will also be on stable medication regimens for at least 


three months prior to enrollment. Exclusion criteria: Cases will be excluded if any of the following are 
applicable: 1) closed epiphyses; 2) active or suspected neoplasia; 3) intracranial hypertension; 4) hepatic 
insufficiency; 5) renal insufficiency; 6) cardiomegaly/valvulopathy; 7) allergy to IGF-1; 8) patients with comorbid 
conditions deemed too medically compromised to participate.  
Drug Administration: IGF-1 (Increlex) is an aqueous solution for injection containing human insulin-like 
growth factor-1 (rhIGF-1) produced by recombinant DNA technology. We have received an IND exemption 
from the FDA (#113031) to conduct the trial. Based on the package insert, dose titration will be initiated at 0.04 
mg/kg twice daily by subcutaneous injection, and increased, as tolerated, every week by 0.04 mg/kg per dose 
to a maximum of 0.12 mg/kg twice daily. This titration is justified based on results from the trial in Rett 
syndrome and our preclinical data which suggests that 0.24 mg/kg/day is effective in reversing 
electrophysiological deficits whereas 0.12 mg/kg/day is not as effective. We aim to reach the therapeutic dose 
as quickly as is safe and tolerated in order to allow maximum time for clinical improvement. Doses may be 
decreased according to tolerability by 0.04 mg/kg per dose. Medication will be administered twice daily with 
meals, and preprandial glucose monitoring will be performed by parents at treatment initiation, prior to each 
injection, and until a well tolerated dose is established. Parents will be carefully trained in finger stick 
monitoring, symptoms of hypoglycemia, and medication administration. 
Outcome measures (Table 1): Efficacy measurements will be taken at baseline of each treatment 
phase, and at weeks 4, 8, and 12 of each treatment phase. Safety and tolerability will be measured every two 
weeks throughout the trial during monitoring visits and phone calls (see Adverse Events). All safety and 
efficacy measurements will be repeated four weeks post-treatment to ensure safety and explore maintenance 
of treatment effects. Primary and secondary outcomes will be measured by an independent evaluator who is 
blind to side effects to prevent the risk of bias. All evaluators will maintain a minimum of 80 percent reliability 
through ongoing training and routine reliability assessments. Primary outcome: ABC-SW (Aman et al., 1985). 
The ABC is a rating scale used to monitor an array of behavioral features, including social withdrawal (i.e., 
Lethargy subscale). It was chosen as the primary outcome measures because our preliminary data suggest 
that it accurately reflects the phenotype and because the ABC has been well validated in both intellectually 
disabled and ASD patients and is currently accepted as an appropriate outcome measure within the field of 
pediatric psychopharmacology research (Aman et al., 2010). Secondary outcomes: Clinical Global Impression-
Improvement and Severity Scales (CGI-S; CGI-I; Guy, 1976). The CGI-S and CGI-I are 7-point rating scales 
commonly used to measure symptom severity and treatment response in studies of patients with intellectual 
disability and ASD (Aman et al., 2002; RUPP, 2005a; 2005b). Exploratory outcomes targeting core symptom 
domains of ASD: Language using the Macarthur-Bates Communicative Development Inventory (MCDI; Fenson 
et al., 1993; 2007), Vineland Adaptive Behavior Communication Domain (Sparrow, 1984), and Language 
Environment Analysis (LENA; Warren et al., 2010); social attention using the Social Orienting Task (Dawson et 
al., 2004); repetitive behavior using the Repetitive Behavior Scale-Revised total score (RBS-R; Bodfish et al., 
2000); Sensory sensitivity and sensory seeking behavior using the Sensory Profile (Dunn, 1999); Adaptive 
functioning using the Vineland Adaptive Behavior Composite (Sparrow, 1984); Caregiver strain using the 
Caregiver Strain Index (CSI; Brannan et al., 1997); All of the selected exploratory measures have been 
previously validated as measurement tools in ASD populations and we aim to assess their utility in detecting 
change with IGF-1 treatment in SHANK3 deficiency.   
Language Testing will be performed with a combination of standardized measures that rely on 
parent/caregiver report, and objective, naturalistic assessments. Dr. Helen Tager-Flusberg (see Letter of 
Support) co-chaired a working group assembled by the National Institute on Deafness and Other 
Communication Disorders (NIDCD) which recommended using a combination of measures for improving 
language assessment and developing benchmarks of expressive language for use as treatment outcome 
measures (Tager-Flusberg et al., 2009). Two objective approaches can be taken with expressive natural 
language samples: verbatim transcription followed by coding with analysis using supporting software (e.g., 
Systematic Analysis of Language Transcripts; Miller & Chapman 2008) or automated technologies such as 
LENA.  A recent study compared vocal production in 26 young children diagnosed mainly with Autistic Disorder 
to 78 typically developing controls using a digital language processor (DLP) and LENA (Warren et al., 2010). 
Audio processing algorithms measured the amount of vocalizations produced during a 12-hour period in the 
children‟s natural environment. Significant differences in vocal production were found between groups and this 
study provides proof of concept that automated measurement can capture and distinguish speech-related and 
non-speech vocalizations in children with language delays and ASD. In addition, LENA measurements were 
positively correlated with previously validated parent report measures (Warren et al., 2010), including the MCDI 


(Fenson et al., 1993; 2007). In the proposed study, LENA sampling will occur pre- and post-treatment during 
the semi-structured ADOS-G in the clinic and during a 12-hour time period in the child‟s naturalistic home 
environment. Software quantifies and analyzes language output to count the number of times a child vocalizes 
during a given period and then filters out vegetative sounds such as respiration and fixed signals like cries.  
Social Attention measurement will also be piloted using a Social Orienting Task (Dawson et al., 2004) 
as an exploratory outcome. Dawson and colleagues have developed the term „social orienting impairment‟ 
which refers to the failure in children with ASD of orienting spontaneously to naturally occurring stimuli in their 
environment (Dawson et al., 1998). Impairments in joint attention and social orienting reflect core social deficits 
and specifically differentiate young children with ASD from those without ASD (Ventola et al., 2007; Dawson et 
al., 2004). It has been suggested that early social attention deficits deprive children of social information input 
and lead to disrupted neural and behavioral development (Mundy & Neal, 2001). Failure of social orienting may 
represent one of the earliest and most fundamental social deficits in ASD (Dawson et al., 1998). In addition, 
social attention has been shown to be critical for the acquisition of verbal and gestural communication 
(Carpenter et al., 1998) and possibly intellectual functioning (Poon et al., 2011). The proposed study will 
replicate the social orienting task developed by Dawson and colleagues (2004). Orienting is defined as turning 
the head or eyes toward an auditory stimulus and a series of four social (e.g., calling the child‟s name) and four 
non-social (e.g., phone ringing) stimuli will be delivered three times each. A standard and familiar testing room 
will be used and the presence, latency, and duration of orienting (e.g., turning the head or eyes) will be 
measured by trained coders through a one-way mirror and the use of video. We aim to explore the use of this 
measure and to assess its utility as an outcome measure sensitive to change with treatment. 
Adverse Events (AEs). Monitoring AEs will be conducted during scheduled and unscheduled visits 
using an adapted semi-structured interview, the Safety and Monitoring Uniform Report Form (SMURF) every 
two weeks, and extensive clinical and laboratory assessments every four weeks (see Section on the Protection 
of Human Subjects). AEs will be carefully documented with respect to severity, duration, management, 
relationship to study drug, and outcome. Severity will be graded using a scale of mild, moderate, or severe.  
Table 1: Outcome Measures 
Baseline 
Phase 1 and 2 
Wk 4 
Phase 1 and 2 
Wk 8 
Phase 1 and 2 
Wk 12 
Phase 1 and 2 
Post-study 
Social:  
ABC-SW subscale  
Social Orienting Task 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Language: 
LENA 
MCDI 
Vineland subscales 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Repetitive Behavior:  
Repetitive Behavior Scale 
X 
X 
X 
X 
X 
Other: 
Sensory Profile 
CGI Scales 
Caregiver Strain Index 
Vineland Behavior Composite 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Data Analysis: This trial is using a randomized cross-over design, thus, time of assessment is nested 
(repeated) within treatment and treatment is nested within subjects. The between subject randomization 
variable is Order. The most appropriate analysis depends on the presence of order of treatment effects. As 
such, we will consider several analytic strategies, including 1) fully within subject design; 2) within subjects 
design with order as a between subjects factor; 3) first phase only (between subjects design). The within 
subjects design using order as a between subjects factor (2) will have 8 observations/subject, reflecting the 
within subject time by treatment effects. However, a between subjects Order variable would be included to 
evaluate the differential effect of treatment over time in the context of order. If the three-way interaction 
involving order (time by treatment by order) was significant, or any other order effects were detected, this 
would preclude the use of the fully within subject design that ignored order. Mixed effect regression is our 
primary analysis and we anticipate estimating an unstructured covariance matrix (“MANOVA”) for the error 
term. However, if all order effects appear to be negligible as anticipated, we will consider the fully within 
subjects design (1) where the model would again focus on treatment and time, but treatment would also be a 
within subjects factors with a total of 8 observations/subject. Finally, as an alternative strategy, we may also 
use the first phase only analysis (3) that would examine data from the first 12 weeks only as a placebo-


controlled, parallel group study. The model for this design is a 4 (time) by 2 (treatment) design with repeated 
measures on the time factor. We would use mixed effects regression with group dummy coded as 0=placebo 
and 1=control and time coded naturally as weeks (0, 4, 8, and 12). Here the primary focus would be the time 
by treatment interaction, which estimates the differential change in the two groups on the outcome measures.  
Sample Size and Statistical Power: Power estimates are based on a sample size of 18 individuals using 
baseline to week 12 change scores. Our Type I error rate (α) was set at .05 and we have adequate power to 
detect large effects in the within-subject analysis (1).  A large effect size is deemed feasible based on the 
potentially disease modifying effects 
of IGF-1 and evidence of large 
effects with risperidone (RUPP, 
2002) and aripiprazole (Owen et al., 
2009) using the ABC as the primary 
outcome measure. However, our primary aim is to evaluate feasibility and detect signal of improvement. 
  Expected outcomes. We expect to provide evidence for the safety and feasibility of IGF-1 in 
ameliorating social withdrawal in children with Autistic Disorder. Further, we expect to demonstrate that IGF-1 
is associated with improvement on secondary outcomes of social impairment, language delay, and repetitive 
behavior, as well as on functional outcomes of global severity and caregiver strain. We further hypothesize that 
treatment with IGF-1 will result in improved expressive speech, reflected by an increase in the frequency  of 
vocalizations, increased well-formed babbles, increase in the proportion of speech sounds to non-speech 
vocalizations and increases in words and turn-taking as measured by LENA. We also predict language 
increases will be evident across assessment settings, the clinic and home. Functional improvements in 
language are not expected in the short-term treatment, but will be evaluated for indication of a signal on this 
clinically meaningful outcome. Significant improvements on measures of life skills (e.g. Vineland) are likewise 
not expected in the short-term, but will be evaluated at major study time points to provide indications of 
potential impact on functional skills domains. If positive, results from this clinical trial will demonstrate 
potentially disease-modifying effects on core and associated symptoms of ASD and may inform future trials.  
Timeline and Milestones. We will require six months for study preparation and 18 months for data 
collection at a randomization rate of one subject per month. The last subject will be randomized in July, 2015 to 
allow for completion of the trial and leave five months for data cleaning, analysis, and manuscript preparation 
Potential problems and alternative strategies. Crossover trial designs carry risks of treatment order 
effects. We have provided a four-week washout period to minimize this risk and will use a between subjects 
Order variable to evaluate the differential effect of treatment over time in the context of order. We believe this 
design is important because SHANK3 deficiency is a rare disease without available treatments and all patients 
will be afforded the opportunity to receive active medication; the cost of IGF-1 does not make an open label 
extension trial feasible at this time. Second, the burden of frequent monitoring visits and subcutaneous 
injections risks subject withdrawal; we will use the intent to treat principle so all randomized patients will be 
included in the data analysis. Third, concerns about recruitment feasibility must be raised with rare diseases. 
We have established an excellent working relationship with the national Foundation for affected families (see 
Letter of Support) and have already evaluated 32 children. There has never been a treatment trial in this 
devastating disorder and 52 patients have thus far expressed interest in participating. Finally, the possibility 
that our hypotheses are not supported must be considered because the preliminary evidence is drawn from a 
preclinical mouse model and we do not have clear evidence for our phenotypic targets. Yet, we have selected 
a measurement tool (ABC) validated in developmentally delayed populations, sensitive to change with 
treatment, and reflective of the phenotype in our preliminary studies. Several secondary and exploratory 
outcomes will also be available for analysis and will provide meaningful data for future research should signal 
be detected elsewhere and not on the primary outcome. Standardized measures of receptive and expressive 
language (e.g., Vineland) that we use as part of our studies may not be sensitive change in this intervention 
trial as standard error of measurement is approximately three months. For this reason, we have chosen an 
additional focus on measures of expressive language using natural language samples and objective 
measurement of language production in semi-structured and naturalistic settings. 
Future directions. Future studies will refine and characterize the phenotype using functional 
neuroimaging and prospectively studying the natural history of the disorder. If results are promising with IGF-1, 
a future clinical trial will include the identification of minimal effective dose and potential biomarkers to predict 
treatment response. Pilot studies to explore the use of IGF-1 in ASD not associated with SHANK3 deficiency 
are also being proposed (IND #113450).  
Effect Size 
Full Within Subject 
Within Subject x Order 
Phase 1 Between Group
.80 
.89 
.56 
.36
1.00 
.98 
.75 
.51
1.20 
.998 
.88 
.67