Pediatric mental health treatment is a crucial area of health care that affects the well-being and development of millions of children worldwide. Transcranial Magnetic Stimulation (TMS) is a non-invasive and promising treatment option that uses magnetic pulses to stimulate specific regions of the brain involved in various cognitive and emotional processes. TMS has been shown to have beneficial effects on various adult mental health disorders, such as depression, anxiety, obsessive-compulsive disorder, and post-traumatic stress disorder. However, the use of TMS in children is still relatively new and under-researched.

Current Applications of TMS in Pediatric Mental Health

 

TMS has been used in pediatric neurology and psychiatry for both diagnostic and therapeutic purposes. TMS can be used to measure the cortical excitability, connectivity, and plasticity of the brain, as well as to change the neural activity and function of specific brain regions. Specific studies have examined TMS efficacy in treating conditions such as brain damage, chronic brain diseases, and functional recovery in children. These studies provide a foundation for further exploration of TMS’s potential in pediatric mental health.

One of the pioneering studies examining the application of TMS in pediatric neurology and psychiatry demonstrated that TMS was well-tolerated among children and adolescents, with minimal side effects reported.¹TMS has also shown promise in treating various neurological and psychiatric conditions in children. For example, TMS has been used to improve motor function and language recovery in children with stroke, cerebral palsy, and traumatic brain injury.^2,3 TMS has been used to enhance learning and memory in children with developmental dyslexia and attention deficit hyperactivity disorder (ADHD).⁴  However, the evidence for the efficacy of TMS in pediatric mental health disorders is still limited and inconclusive, and more studies are needed to establish the optimal parameters, protocols, and targets of TMS for different conditions and populations.

Potential Applications of TMS in Pediatric Population

 

As we look ahead, there are several exciting avenues for the application of TMS in pediatric mental health:

A. ADHD and Cognitive Enhancement

Attention deficit hyperactivity disorder (ADHD) is one of the most common psychiatric disorders in children, characterized by difficulties in attention, hyperactivity, and impulsivity. However, a notable percentage of patients, ranging from 10 to 30 percent, do not exhibit a favorable response to conventional pharmacotherapy.⁴ Concerns about adverse effects and the potential for misuse can limit the use of these medications in certain cases. In addition to medications and psychotherapy, patient and family education are also employed as treatment modalities for ADHD, either independently or in conjunction with medication-based approaches. Given that psychotherapy may have a delayed onset of therapeutic effects and some individuals may not respond well to medications or may experience intolerance, TMS of the brain could emerge as an alternative therapeutic option with improved safety and tolerability for the treatment of adolescents with ADHD.⁴

Within ADHD, children grapple with difficulties related to sustained attention, selective attention, and inhibitory control. Researchers have identified that TMS can be used to enhance one’s capacity to regulate attention. This includes bolstering the ability to concentrate on relevant elements (referred to as top-down attention) or noticing unexpected stimuli (known as bottom-up attention).⁵ Moreover, TMS can influence the capability to direct attention to sudden changes in environment. Research has also shown that children with ADHD, who have alterations in the prefrontal cortex—a crucial brain region ADHD—saw improvements inattention, hyperactivity, and impulsivity symptoms after receiving TMS. ³

TMS has shown promise in impacting neural activity in regions associated with attention and executive function in ADHD, potentially offering an alternative or complementary approach to traditional treatments.

B. Autism Spectrum Disorder (ASD)

Autism Spectrum Disorder (ASD) is a complex neurodevelopmental condition that affects social interaction, communication, and behavior. TMS may hold potential as a therapeutic tool to address specific symptoms associated with ASD.

TMS has the potential to impact the connectivity and acitivty irregularities seen in ASD by acting on specific brain regions associated with ASD symptoms. For instance, TMS can be directed towards various areas, including the prefrontal cortex (PFC), responsible for executive functions, social cognition, and emotion regulation; the temporoparietal junction (TPJ), involved in theory of mind, perspective-taking, and empathy; the fusiform gyrus (FG), responsible for processing faces; the posterior superior temporal sulcus (pSTS), related to biological motion perception; the anterior cingulate cortex (ACC), associated with social motivation; and the cerebellum, linked to motor coordination, cognition, and emotion. These processes typically enable individuals to adaptively respond to environmental demands through contextually relevant and goal-oriented behavior, involving aspects like planning, self-regulation, and self-monitoring. However, in the context of ASD, it appears that several of these higher-order cognitive processes may not function optimally, resulting in individuals with ASD exhibiting more reactive and less adaptable behaviors in their surroundings.⁶

Numerous studies have explored the impact of TMS on ASD outcomes. Some studies have reported positive results in addressing social communication and interaction impairments (SCI) as well as restricted and repetitive behaviors (RRB) in individuals with ASD. A comprehensive meta-analysis, encompassing over 800 participants across 22 studies, revealed that non-invasive brain stimulation methods like TMS have the potential to remedy core ASD symptoms. These improvements span a range of symptoms areas, including stereotyped behavior, executive function, irritability, language function, hand-eye coordination, social interaction abilities, and emotional states, depending on the specific brain region targeted.⁷

By targeting brain regions implicated in social cognition and sensory processing, TMS could improve social functioning and other difficulties in ASD.

C. Other Neurodevelopmental disorders (Cerebral Palsy (CP))

Cerebral palsy (CP) is a developmental disability that affects children’s ability to control their movements. CP is caused by damage to the brain that occurs before, during, or shortly after birth. The damage can affect different parts of the brain and result in different types of CP, such as spastic, dyskinetic, ataxic, or mixed. CP can also cause other problems, such as seizures, vision, hearing, or speech impairments, intellectual disabilities, or behavioral issues. CP is the most common motor disability in childhood, affecting about 1 in 345 children in the United States.

The use of TMS as a treatment for children with CP is growing. TMS has been shown to enhance motor function, reduce spasms, restore speech function, and alter brain function by modifying developmental plasticity (the ability for the brain to change and form new connections).² TMS has been proven to be a promising intervention for greatly reduce the challenges faced by children with CP.

D. Mood Disorders

Rates of depression in children and adolescents has increased over time. Depression can cause persistent feelings of sadness, hopelessness, and loss of interest in activities that used to be enjoyable. Depression can also affect the way adolescents think, feel, and behave, and can interfere with their school, social, and family life. Depression can have negative consequences for adolescents’ physical, emotional, and cognitive development, and can increase the risk of suicide. Depression in adolescents can be diagnosed and treated by a doctor or a mental health professional, who can conduct a physical exam, lab tests, and a psychological evaluation. The treatment for depression in adolescents may include medication, psychotherapy, or a combination of both. Medication can help balance the brain chemicals that affect mood and emotions.

TMS has proven to work well and be safe for adolescents dealing with depression. Additionally, it tends to have fewer unwanted side effects compared to antidepressant medications.⁸

Cognitive-Behavioral Therapy (CBT) is a widely used and effective treatment for various pediatric mental health disorders, including depression.⁹ TMS could be explored as an adjunct to CBT, enhancing its outcomes. By priming neural networks associated with emotional regulation and cognitive flexibility, TMS may amplify the benefits of CBT, particularly in cases where standard therapy alone may not be sufficient.

Building upon its successful application in pediatric neurology and psychiatry, TMS holds potential as a safe and effective intervention for children with various neurological and mental health disorders. As we look to the future, continued research is essential to advancing TMS in pediatric mental health care.

References

1. Frye, R. E., Rotenberg, A., Ousley, M., & Pascual‐Leone, Á. (2007). Transcranial magnetic stimulation in child neurology: current and future directions. Journal of Child Neurology, 23(1), 79-96. https://doi.org/10.1177/0883073807307972
2. Sun, Y. Y., Wang, L., Peng, J. L., Huang, Y. J., Qiao, F. Q., & Wang, P. (2023). Effects of repetitive transcranial magnetic stimulation on motor function and language ability in cerebral palsy: A systematic review and meta-analysis. Frontiers in pediatrics, 11, 835472. https://doi.org/10.3389/fped.2023.835472
3. Rathinam, C., Mohan, V., Bill, P., Yates, D., Gupta, R., & Peirson, J. (2023). Impact of transcranial magnetic stimulation on motor function in children with acquired brain injury: a scoping review protocol. BMJ paediatrics open, 7(1), e001885. https://doi.org/10.1136/bmjpo-2023-001885
4. Memon A. M. (2021). Transcranial Magnetic Stimulation in Treatment of Adolescent Attention Deficit/Hyperactivity Disorder: A Narrative Review of Literature. Innovations in clinical neuroscience, 18(1-3), 43–46.
5. Riddle, J., Hwang, K., Cellier, D., Dhanani, S., & D’Esposito, M. (2019). Causal evidence for the role of neuronal oscillations in top–down and bottom–up attention. Journal of Cognitive Neuroscience, 31(5), 768-779. https://doi.org/10.1162/jocn_a_01376
6. Casanova MF, Sokhadze EM, Casanova EL, Li X. Transcranial Magnetic Stimulation in Autism Spectrum Disorders: Neuropathological Underpinnings and Clinical Correlations. Semin Pediatr Neurol. 2020 Oct;35:100832. doi: 10.1016/j.spen.2020.100832. Epub 2020 Jun 24. PMID: 32892959; PMCID: PMC7477302.
7. Liu, A., Gong, C., Wang, B., Sun, J., & Jiang, Z. (2023). Non-invasive brain stimulation for patient with autism: a systematic review and meta-analysis. Frontiers in psychiatry, 14, 1147327.
8. Narang, P., Madigan, K., Sarai, S., & Lippmann, S. (2019). Is Transcranial Magnetic Stimulation Appropriate For Treating Adolescents with Depression?. Innovations in clinical neuroscience, 16(9-10), 33–35.
9. Hameed, M. Q., Dhamne, S. C., Gersner, R., Kaye, H. L., Oberman, L. M., Pascual‐Leone, Á., … & Rotenberg, A. (2017). Transcranial magnetic and direct current stimulation in children. Current Neurology and Neuroscience Reports, 17(2). https://doi.org/10.1007/s11910-017-0719-0