Acta Pædiatrica ISSN 0803-5253

REVIEW ARTICLE

Autism spectrum disorders: linking neuropathological findings to treatment
with transcranial magnetic stimulation
Manuel F. Casanova (m0casa02@louisville.edu)1, Estate Sokhadze1, Ioan Opris2, Yao Wang1,3, Xiaoli Li3
1.Department of Psychiatry, University of Louisville, Louisville, KA, USA
2.Department of Physiology and Pharmacology, Wake Forest University School of Medicine, Winston-Salem, NA, USA
3.State Key Laboratory of Cognitive Neuroscience and Learning, Beijing Normal University, Beijing, China

Keywords
Autism spectrum disorder, Cerebral cortex,
Minicolumn, Transcranial magnetic stimulation
Correspondence
M F Casanova, MD, Gottfried and Gisela Kolb
Endowed Chair in Psychiatry, Department of
Psychiatry, University of Louisville, 500 South
Preston Street, Bldg A, Rm 217, Louisville, KY
40202, USA
Tel.: +1(502)852-4077 |
Email: m0casa02@louisville.edu

ABSTRACT
Postmortem studies in autism spectrum disorder (ASD) individuals indicate the presence
of abnormalities within the peripheral neuropil space (PNS) of cortical minicolumns. The
geometrical orientation of inhibitory elements within the PNS suggests using repetitive
transcranial magnetic stimulation (rTMS) to up-regulate their activity. Several rTMS trials in
ASD have shown marked improvements in motor symptomatology, attention and
perceptual binding.
Conclusion: rTMS is the first therapeutic attempt at ASD aimed at correcting some of its
core pathology.

Received
10 December 2014; revised 15 January 2015;
accepted 20 January 2015.
DOI:10.1111/apa.12943

INTRODUCTION
Bauman and Kemper’s pioneering histoanatomic studies
briefly described the presence of cerebral cortex pathology
within their series of autism spectrum disorder (ASD)
individuals. Described changes included an indistinct laminar pattern and minor cortical malformations or dysplasias
(1). Nevertheless, the first group to emphasise the role of
the cerebral cortex in the neuropathology of ASD was that
of Bailey et al. (2). Since then many studies have underlined
individual aspects of this pathology including changes in
neuronal size and density (3), abnormalities of minicolumnar morphometry (4,5), heterotopias (6), the presence of
supernumerary cells in both the molecular layer and the
subplate region (7) and dysplasias (8). The prominence and
prevalence of cortical pathology along with reports of
widespread heterotopias has prompted some researchers to
suggest that, in some cases, ASD results from the heterochronic divisions of germinal cells (periventricular and
rhombic lip) giving rise to the desynchronisation in matu-

Abbreviations
ASD, Autism spectrum disorder; DLPC, Dorsolateral prefrontal
cortex; EEG, Electroencephalography; ERP, Event-related potential; GABA, Gamma-aminobutyric acid; HF, High frequency;
HRV, Heart rate variability; kA, Kilo-amps; LF, Low frequency;
M1, Primary motor cortex; MRCP, Movement related cortical
potential; PNS, Peripheral neuropil space; rTMS, Repetitive
Transcranial Magnetic Stimulation; S1, Primary somatosensory
cortex; SCL, Skin conductance level; SMA, Supplementary
motor area; TMS, Transcranial Magnetic Stimulation.

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ration between radially derived pyramidal cells and tangentially derived interneurons (9). This abnormality of
germinal cell division and later migration appears to explain
many of the reported neuropathological and clinical aspects
of both idiopathic and syndromic autism. In this regard,
autism can be considered a neurodevelopmental disorder as
it impairs the growth and development of the brain.
The cerebral cortex provides the mainboard of crucial
circuitry that allows for the emergence of higher cognitive
functions such as attention, memory, judgment, language
and empathy. Impairments of corticogenesis usually
manifest themselves early in life as varying degrees of
cognitive dysfunction for which they are traditionally
labelled as neurodevelopmental disorders. Understanding
the mechanisms for the development of the cerebral cortex

Key notes   

The presence of heterotopias and dysplasias in the
brains of autistic individuals clearly frame the condition
as a neurodevelopmental disorder.
The smallest unit of information processing within the
modular organisation of the cerebral cortex is the
minicolumn.
The presence of neuronomorphometric abnormalities
within the periphery of minicolumns in the brains of
autistic individuals suggests using low frequency repetitive transcranial magnetic stimulation (rTMS) as a
possible treatment intervention.

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Casanova et al.

Autism and TMS

is therefore of major importance when discussing the
pathogenesis of autism.
In this article, we will summarise recent findings regarding the organisation of the cerebral cortex, its ontogenetic
origin and related neuropathological findings in the brains
of ASD individuals. Subsequently, we will describe how the
topographical specificity of these abnormalities, being
primarily within the periphery of minicolums, is amenable
to treatment with repetitive transcranial magnetic stimulation (rTMS). We finalise the article by summarising the
results of different clinical trials using rTMS in ASD.

CORTICAL MODULARITY
The cerebral cortex is organised into different areas that
process information in a hierarchical feedforward manner.
Although it would be profitable to differentiate these areas
in a quantitative and unbiased manner this endeavour has
been fraught with difficulties. At present, techniques for
visualising cell morphometry can only poorly demarcate
large portions of the cortex. About two-thirds of the
cerebral cortex lies buried in folds under the surface of
the brain. The curvature and repositioning of cellular
elements in these abstruse areas has confounded researchers to such an extent that their existence has been ignored
in different neuroanatomical treatises. Indeed, the limitation of cytoarchitectural techniques led neuroanatomists to
conclude that attempts at subdividing the cerebral cortex
by histological methods would prove unprofitable, if not
impossible. For many decades it has thus been recommended to complement cytoarchitectural surveys with
other techniques, notably those based on fibre connectivity.
Indeed the lack of ‘cookie cutter borders’ between cytoarchitecturally defined parcellations of the cerebral cortex has
led to an alternate affiliation system based on functional
connections.
Attempts at parsing the cerebral cortex by means of
functional connections have yielded a limited number of
discrete areas (10–12) where Information travels in a
stereotyped manner going from the extrapersonal space to
idiotypic cortex (primary sensory and motor areas) and
from there to homotypical (unimodal and heteromodal),
paralimbic and limbic cortices. As there is an infinite
number and variety of inputs the proposed computation
system begs the question as to how intrinsic cortical circuits
are adapted to so many different tasks. According to
Creutzeldt (13) the cerebral cortex overcomes this obstacle
by instantiating a canonical circuit that provides for similar
transformations throughout the cerebral cortex (Fig. 1).
This view upholds that functional differences among brain
regions depend on variations in input sources, output
targets, interconnectivity and the modulatory effect of
inhibitory influences.
Common patterns in the organisation of nerve cells and
their connections (i.e. microcircuits) have been described in
the cerebral cortex of all examined mammalian species. 
was the first to discuss the physiological role
Lorente de No
of ‘vertical cylinders’ of cells when he famously said: ‘All the

Figure 1 Schematic display of principal cell types and their interconnections
found in the minicolumn, the canonical microcircuit of six-layered cerebral
cortex (neocortex). Ch: chandelier cell; DB: double bouquet cell; LB: large basket
cell; SB: small basket cell; SS: spiny stellate cell.

elements of the cortex are represented in it, and therefore it
may be called an elementary unit, in which, theoretically,
the whole process of transmission of impulses from the
afferent fibre to the efferent axon may be accomplished’
(14). Later on electrophysiological studies by Mountcastle
helped define a minicolumnar organisation of neurons that
encoded similar features and shared nearly identical terminal fields (15). Over the years it has become clear that the
repetitive and ‘on-demand’ event-based nature of the
proposed canonical circuit is an enabler of neuroplasticity
that allows different areas of the cerebral cortex to process
information stemming from varied sources, including some
that are artificial in nature.
In recent years, Opris et al. (16) have implemented the
use of custom-designed conformal (i.e. following the longitudinal contour of the cortex) multielectrode recording
arrays to describe the coding of interlaminar circuitry
within and between minicolumns (Fig. 2). Their group has
found that substituting firing patterns of layer 5 neurons
with electrical stimulation during minicolumnar transmission from layers 2/3 improved task performance (target
selection) in primates (17). More importantly, when microelectrode stimulation was applied following the pharmacological ablation of a cortical region, the researchers
observed recovery of performance (18). This finding, based
on encoding the pattern of signals of individual minicol-

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Figure 2 Interlaminar recording and MIMO stimulation model: (left panel) rasters and peri-event histograms depict the activity of supra-granular (blue) and infragranular (red) cell layers. Overlay cross-correlograms show inter-laminar firing increase following the presentation of targets compared to pre-target epoch. Recording
array with the MIMO model for recording in layer 2/3 and stimulation in layer 5. Stimulation effect (on the right panel) compares the cumulative effect in single session
and population tuning for MIMO stimulation (red) vs. layer 5 prefrontal cortical activity (dark blue dotted line). Overall MIMO stimulation effect (red) is significantly
greater than no-stimulation and the chance level. Asterisks **p < 0.001, ANOVA.

umns, is the first reported intervention where a neuroprosthesis has been used to successfully restore diminished
cognitive function (19).
Construct validity for the minicolumn, and the appropriateness of inferences based on their existence, is derived
from multiple sources. Population analysis of neurons
within the same receptive field in primary somatosensory
cortex (SI) shows that diversity within segregates is
attributable to variability among minicolumns rather than
within minicolumns (20,21). Metabolic studies (2-deoxyglucose) of the receptive fields of monkey’s SI evoked by
skin stimuli show column-shaped patches of label comprised of active minicolumns interspersed with less active
minicolumns (22). Two-photon imaging of calcium influxes
evidences an organisation of cortical response fields comprised of columns 1–2 cell wide (23). Similarly, studies
using labelled retroviruses and multiple cell recordings
illustrate a propensity for pyramidal cells to develop
connections with sister cells rather than to neighbouring
non-siblings (24). This affinity may be the result of the
close apposition of neuroblasts as they migrate radially
towards the cortical plate. Indeed, early during brain
development these cells are connected to each other via
gap junctions thus procreating a suitable scenario for
Hebbian reciprocity. Minicolumns are therefore highly
integrated structures where connections within the modules
far exceed those between modules. In this regard, minicolumns are modules within a hierarchical system whose
parts are interconnected by anatomical and physiological
relationships fulfilling the function of an informationprocessing unit.

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It is important to note that although different minicolumns appear to convey the same canonical circuit that they
are not clonal elements. Anatomical studies have found
significant minicolumnar variability within and across areas
in individual brains as well as between mammalian species.
This variability (e.g. number of neurons and synaptic
elements) between minicolumns may be an adaptive feature
that is responsible for both fault tolerances within larger
networks (e.g. macrocolumns) as well as for the competition among modules that is necessary for circuit optimisation (25).

CORTICOGENESIS AND AUTISM
During corticogenesis germinal cells surrounding the ventricles divide and migrate to the cortical plate to form a
consecutive series of strata one on top of another following
an inside–out configuration (Fig. 3). Neuroblasts derived
from periventricular germinal cells migrate radially towards
the cortical plate using a glia projection as a scaffold.
Computerised image analysis of the radial translaminar
arrays of pyramidal cells has shown a chronological
continuity from early on in gestation (i.e. the ontogenetic
minicolumn) through postnatal maturation and ageing (26).
These neurons mature in synchrony with cells that are
themselves derived from a tangential migratory stream
stemming primarily from the ganglionic eminences. The
radially migrating cells (future pyramidal cells) and tangentially derived neurons (future interneurons) provide for
functional units called dyads, e.g. pyramidal-double bouquet cell dyads, pyramidal-basket cell dyads. Deficits of

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Casanova et al.

Figure 3 Coronal section of the human brain during embryonic development.
The clear arrowheads illustrate the tangential migratory pathway of cells (future
interneurons) from the lateral and medial ganglionic eminences (LGE and MGE,
respectively) to the cortical plate. Interneurons may also originate from the
retrobulbar neuroepithelium of the lateral ventricle and from the cortex itself.
Those interneurons fated for the cortex acquire a superficial and deeper
pathway in order to avoid the embryonic striatum. A set of dark arrowheads
illustrates how neuroblasts migrate out of the ventricular zone and into the
cortical plate (future pyramidal cells) following a radial pathway. An excitatory/
inhibitory imbalance may result from desynchronisation of cells as they
undertake their radial and tangential migrations. Because interneurons are
generated at such distant sites their migration may be susceptible to disruption
from a large variety of sources. Reprinted from Medical hypotheses, volume 83,
Casanova et al., ‘Autism as a sequence’, pp. 32–38, copyright 2012, with
permission from Elsevier.

neuronal migration are likely to impair the formation of
these dyads thus promoting an excitatory/inhibitory bias
capable of explaining the high prevalence of epilepsy among
neurodevelopmental disorders.
Some abnormalities of the cerebral cortex pinpoint to a
developmental malformation deficit. Occasional brains
exhibit an excessive number of small convolutions (gyri)
and, in others, sulci have been noted to run in an abnormal direction (27). Microscopic examination has revealed
indistinct or disordered lamination, small neurons and
changes in cell-packing density (2,28). Bailey et al. noted
the presence of increased number of neurons in both Layer
1 and the subcortical white matter (2). These findings,
indicative of a migrational disorder, have been reproduced
by Avino and Hutsler in a study using computerised image
analysis and in a qualitative study that surveyed whole brain
serial sections by Wegiel et al. (7,8). More recently, the
presence of focal cortical dysplasias was quantitated in
serial sections of ASD individuals as compared to neurotypicals (29). Morphometric analysis of neurons within
involved patches suggested a reduction in the overall
number of interneurons and a reduction in size of remaining pyramidal cells.
Several studies have used unbiased semiautomated imaging methods to analyse minicolumnar morphometry in

Autism and TMS

ASD. In one study, photomicrographs from Brodmann
areas 9, 21 and 22 were decomposed according to a greyscale distribution and subsequently thresholded to define
cellular kernels in nine ASD individuals and an equal
number of neurotypicals (4). The least square method was
used to fit a radial axis through the clusters of Nissl stained
elements in order to define a mean tangential axis-to-axis
distance, i.e. minicolumnar width. The results showed
significant narrowing (p = 0.034) of minicolumns in ASD
with the greatest decrease found in the PNS compartment.
Thinning within the PNS of minicolumns in ASD was
observed across layers (i.e. supragranular, granular, infragranular) suggesting involvement of a common anatomical
element throughout the cortical width of ASD individuals.
The findings were latter corroborated using the same
patient population but with a different parcellation technique: the grey level index (GLI) (3).
Neuropathological findings regarding a minicolumnopathy in ASD was reproduced in an independent population
with investigators blind to diagnoses (5). An algorithm
based on the Delaunay triangulation was used to define the
distribution of edges between image kernels (Fig. 4). The
results were fitted to a bimodal distribution of interneuronal
distances within and between core cell columns. The
findings indicated that in ASD the number and arrangement of pyramidal cells within a minicolumn was preserved
but minicolumnar width was reduced. The researchers also
reported a small but significant reduction in the size of
pyramidal cell perikarya that would serve to bias brain

Figure 4 Minicolumnar fragments visible in a 35 lm thick section from
Brodmann area 22 of a 98-year-old male. These were identified by our
automatic image analysis methods (5). The highlighted fragment spans laminas
III and IV (from top to bottom).

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CLINICAL SIGNIFICANCE OF NEUROPATHOLOGICAL FINDINGS
The inhibitory defect in the cerebral cortex of ASD
individuals focuses around its minicolumnar organisation
(30). Positive feedback without inhibitory modulation
serves to drive a system harder towards signal saturation
and deformation. For most intelligent systems it is desirable
to control the gain of a signal through negative feedback
rather than allowing it go towards its extremes. A defect of
lateral inhibition would enable individual minicolumns to
coalesce into islands of excitatory activity. The inhibitory
deficit procreated by the minicolumnopathy, alongside grey
matter heterotopias, offers a suitable clinicopathological
correlate with both the cognitive deficits and seizures
observed in many autistic individuals. A similar imbalance
in the excitatory/inhibitory bias (i.e. stochastic resonance)
may account for abnormalities in multiple sensory domains
(see below) (34).
Stochastic resonance is a phenomenon where a weak
signal, normally below levels of detection, can be recognised by adding noise to the system. In the case of ASD the
noise (i.e. signals that add to the ‘intelligent’ input) is
inherent to the system in the form of a hyperexcitable
cerebral cortex (Fig. 5). Under an optimal noise level small
perturbations increase the sensitivity of the system. On the
other hand, non-optimal noise levels decrease its sensitivity,
blurring signal from noise (e.g. the background ‘hiss’ in
communication systems). This mechanism, already demonstrated and applied in neurophysiology (36,37), could help
explain features of concurrent hypo- and hypersensitivity in
ASD, e.g. heightened apprehension to external stimuli and
decreased registration of internal body stimuli.
The interpretation of many of the clinical findings in ASD
appears related to the previously described minicolumnar
pathology (see above). This core pathological feature of
autism is amenable to intervention when considering the
nature of the anatomical elements involved, their location,
and their geometrical orientation in regards to the cerebral
cortex. Some inhibitory elements within the PNS stand at
direct angle to the pial surface. Axons of double bouquet

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connectivity in favour of short corticocortical projections at
the expense of longer ones.
Studies of minicolumnar morphometry in autism indicate
a relative preservation in the size of the core compartment
alongside a significant reduction of the peripheral neuropil
space. The periphery of the minicolumn is the site that
provides for lateral or surround inhibition (30). Mountcastle described this compartment as conferring a strong flow 
gothai
of vertical inhibition to the minicolumn (15). Szenta
stressed the anatomical role of this peripheral compartment
by calling it a ‘shower curtain of inhibition’ (31). Both EEG
and tactile processing studies corroborate the presence of
an abnormality of lateral inhibition in the cerebral cortex of
individuals with ASD (32,33). Flutter stimuli capable of
differentiating between active and inactive inhibitory surrounds are now being used as potential biomarkers in the
diagnosis of autism (33).

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Figure 5 Stochastic resonance illustrated in a model neuron, SRM0 (35). The
model was stimulated with a combination of subthreshold pulses at 25 ms
intervals or 40 Hz, within the gamma band, and a background of random
postsynaptic potentials (PSP) distributed as a Poisson process. In the absence of
background, the subthreshold pulses fail to produce action potentials in the
model neuron. When noise is present at a rate of 500 PSP per second (A), the
neuron spikes occasionally with the gamma-band pulses. At a higher noise rate
of 1000 PSP per second (B), the neuron fires in synchrony with the 40 Hz input
signal. At still greater noise, 2000 PSP per second (C), random firing drowns out
the signal. Vertical bars in each panel indicate the timing of the input pulses.

cells transverse the width of the cerebral cortex forming
tightly interwoven horsetail-like bundles. The regular spacing of double bouquet cells serves to frame the minicolumn
in an inhibitory surround. The large number of axons
stemming from each cell, their length, as well as their
geometrical orientation within the cerebral cortex suggests
their susceptibility to low frequency TMS stimulation
(Fig. 6). The axonal ramifications of these cells would
provide an additive effect to their overall diameter thus
decreasing their resistance and facilitating their proclivity
towards being induced by an external magnetic field.

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Casanova et al.

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B

B

j

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Enhanced
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Figure 6 The principle of rTMS is that a magnetic field (B), varying in strength
over time, induces electric currents (j) parallel to the direction of B. The greatest
effect will be seen in superficial layers of the cortex and outside of sulci, since B
loses strength rapidly with increasing distance from the scalp. This part of the
cerebral cortex includes double bouquet cells, whose long, straight axon bundles
synapse on the basal dendrites of pyramidal cells, creating the inhibitory
surround that isolates a particular minicolumn from its neighbours. Reprinted
from Cutting-edge therapies for autism 2010–2011 by permission of Skyhorse
Publishing, Inc.

However, despite the apparent susceptibility of certain cells
to TMS, especially at lower frequencies, it seems possible
that stimulation results in a compound action potential
comprised of individual pulses in many different types of
axons.

TRANSCRANIAL MAGNETIC STIMULATION
Whenever current flows through a conductor a magnetic
field is generated. For a straight wire the resultant magnetic
field has no polarity and the field strength tends to be small
and of little practical use. Twisting the wire into a loop
forces the flux lines closer together and adds polarity to the
magnetic field. Sliding a bar of a ferromagnetic material
through the coil changes the core’s permeability to flux lines
thus greatly increasing the strength of the magnetic field
produced. A coil with a ferromagnetic core is called an
electromagnet. In contrast with a permanent magnet the
field around the coil or electromagnet exists only when
current flows through the loops of wire. The strength of the
magnetic field thus produced depends on the number of
turns of the coil and the amount of current flowing through
the same. The conformation of the electromagnet serves to
direct the magnetic field lines to a particular foci thereby
increasing flux density and strength but decreasing or
limiting its penetration. For this reason many machines
use an air core with their coiled inductor. Current research
is being directed towards testing new cores and varied
shaped coils that may induce stronger magnetic fields while
improving penetration. At present, depth of penetration of
the induced magnetic field is approximately 30 mms. Since
the surface of the cerebral cortex lies about 20 mms below
the skin, brain stimulation with TMS targets primarily the
crest of gyri.
In transcranial magnetic stimulation (TMS) a bank of
super- or ultracapacitors discharge stored current across an

inductor coil. As the capacitors discharge, a current of high
magnitude, usually several kA, passes through the stimulating coil causing at first a magnetic field to rapidly expand
and then to collapse. For practical purposes stimulation of
tissue elements (alterations in membrane potential) with a
single pulse of TMS is thought to occur during the rising
edge of the applied magnetic field. The resultant magnetic
field is on the order of 1 T, which is approximately 20 000
times the Earth’s magnetic field.
Electromagnetic induction is the process of producing an
electromotive force (voltage) through a conductor by either
moving the same through a stationary magnetic field or by
leaving the conductor still and changing the magnetic field.
In TMS the process of relative motion is caused by the
expanding magnetic field, otherwise the anatomical elements acting as conductors remain stationary. The induced
voltage is influenced by the strength of the magnetic field
applied, the speed of the relative motion between the
conductor and magnetic field, the length of the conductor
and the angle at which the conductor cuts the magnetic
field. The maximum induced voltage occurs in those
conductors standing at ninety degrees to the magnetic field.
Low frequency (<1 Hz) is considered to have an inhibitory effect on the cerebral cortex, for the most part (38), as
it suppresses the excitability of the motor or visual cortex
for motor or phosphene thresholds. Depending on the preexisting baseline excitability level, higher frequencies (considered as 5 Hz and greater) are considered excitatory. At
different frequencies TMS alters the expression of immediate early gene proteins and GABAergic neurotransmission
(39,40). It has therefore been hypothesised that slow rTMS
increases the activation of inhibitory circuits. Indeed, slow
rTMS significantly increases high frequency oscillations and
have no effect on somatosensory evoked potentials over the
primary somatosensory cortex. These oscillations are a
reflection of the activity of intracortical inhibitory neurons
(41). The results suggest that slow rTMS affects cortical
excitability by stimulating interneurons, an effect which
lasts beyond the time of stimulation (42,43). Hoffman and
Cavus in their review of the literature regarding slow rTMS
proposed long-term depression and long-term depotentiation for its mechanisms of action (44). Changes accrued to
these mechanisms appear to accumulate in additive fashion
over repeated sessions.

TRANSCRANIAL MAGNETIC STIMULATION AND AUTISM
Several studies have examined the effects of low frequency
(0.5 Hz–1.0 Hz) rTMS on behavioural, EEG and ERP
outcome measures in children with ASD (45,46). The
studies have been performed as outpatient procedures
usually lasting 20–30 min. Since there may be a risk for
inducing seizures, especially in patients with a hyperexcitable cortex, our group and others have excluded participants with seizures or a family history of the same. As an
additional precaution in rTMS studies we have adjusted the
stimulation intensity (energy of the pulses) below the
patient’s motor threshold. Given the susceptibility of metal

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objects to the effects of a magnetic field, individuals who
use intracranial metallic pieces, pacemakers and/or other
implantable devices have been excluded from participating
in the studies.
Our studies have focused on stimulating the dorsolateral
prefrontal cortex (DLPC) for 6, 12 and 18 weeks. The
tremendous output territory of the DLPC makes it a
connection hub within the small-world network of corticocortical connectivity. It was thought that modulating the
output of the DLPC would procreate a beneficial cascading
to the many areas connected to the same. The age range of
participants in the various studies was 8–27 with a mean of
14 years. In our first study (n = 8 children with ASD, n = 5
wait-list participants, n = 13 age-matched controls) we
measured the EEG gamma band during a visual attention
task (i.e. recognising a Kanizsa stimuli as either an illusory
figure or not) and then measured the EEG gamma band
after six sessions of rTMS treatment (47–49). Binding of
widely distributed cell assemblies by these high frequency
oscillations or gamma frequencies (30 Hz–80 Hz) has been
associated with top-down attentional processing and object
perception. In this study, gamma activity in our control
group was found to increase during the presentation of
target-stimuli as compared to non-target stimuli. The power
of the gamma oscillations was higher in the ASD group and
had a shorter latency as compared to controls. After six
sessions of slow rTMS the power of gamma oscillations
decreased over the frontal and parietal locations (on the
same side of the stimulation), and the difference between
gamma responses to target and non-target stimuli significantly increased (Fig. 7). Clinical assessments revealed
significant improvements in repetitive and stereotyped
behaviours.
Gamma band activity has been investigated after 12
sessions of bilateral slow rTMS to the dorsolateral prefrontal cortex (50). In these studies, 16 ASD patients and
nine age-matched controls were assessed while using
Kanizsa illusory figures. Following rTMS treatment ASD
individuals showed significant improvements between relevant and irrelevant visual stimuli. Other studies have

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followed using independent populations showing that
rTMS significantly improves ERP indices of selective
attention, motor response errors, error detection and
correction, and both repetitive behaviours and irritability
(50–53). Evidence from our trials of compromised error
monitoring was deemed of importance as it may underlie an
impairment of self-monitoring which is part of the supervisory attentional system that reviews when and how to use
specific strategies and adjust the same according to environmental changes and task demands (51,52). Individuals
with error monitoring dysfunction may thus show impairments in set shifting abilities and inflexibility in their
capacity to change goals. In schizophrenia, an impairment
in error monitoring predicts poor executive function as
tested with the Penn Conditional Exclusion test (PCET)
(54). TMS may therefore prove to be an intervention that
improves executive functions in addition to behavioural
performance in ASD.
The effects of rTMS have been investigated after 18
weekly session of bilateral DLPC stimulation. This study
used two groups of children with autism (TMS and wait list
group, n = 27 per group) (55). Following the study sessions
there was a significant decrease in amplitude and prolonged
latency in the frontal and fronto-central N100, N200 and
P3a ERP components to non-targets in the TMS group as
compared to the wait-list group. These changes along with
an increase in P2d, centro-parietal P100 and P3b suggest a
greater efficiency of information processing after TMS
treatment.
Bilateral prefrontal rTMS has been used to examine the
effects on evoked and induced EEG gamma phase coherence between frontal and parietal sites during performance
on a Kanizsa illusory figures oddball task (56). The study
consisted of 18 sessions with 32 participants (TMS and wait
list, 16 individuals per group). Results indicated that TMS
had its most significant effect on induced gamma in the
frontal region as suggested by a significant increase after
treatment in frontal gamma coherence in response to
target stimuli compared to the coherence observed in the
wait list group. TMS also increased induced gamma phase

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Figure 7 rTMS modulates evoked EEG gamma frequency oscillations to target and non-target illusory figures at frontal site F7. Following a 12 session-long TMS course,
early gamma response to non-target decreased, whereas gamma oscillation power to target illusory figures increased. Reprinted, with permission, from Frontiers in
autism research, ed. Valerie W. Hu, copyright 2014 World Scientific Publishing.

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Casanova et al.

coherence between ipsi- and contra-lateral frontal and
parietal regions. The data shows that TMS does improve
gamma coherence in autism, especially in the induced
gamma time frame.
The combined use of rTMS and EEG neurofeedback (i.e.
the use of brain activity parameters as feedback to regulate a
function we want to control) has been used to operantly
condition post-TMS EEG changes (57). The underlying
hypothesis was that combined TMS and neurofeedback
therapy would improve executive functions and behaviour
in the treatment group (n = 20) as compared to the wait list
group (n = 22). Results of the integrated neuromodulation
treatment supported the initial hypothesis by demonstrating
significant improvements in the behavioural and ERP
measures of executive functions, as well as significant
changes in EEG outcomes of neurofeedback training such
as frontal theta-to-beta ratio and an increased relative
power of gamma activity.
Heart rate variability and electrodermal activity have
been used as noninvasive measures of autonomic nervous
system activity during rTMS therapy in autism (58). The
study found that an accelerated heart rate in association
with lower heart rate variability (HRV) indexed by low
frequency (LF) to high frequency (HF) ratio (LF/HF of
HRV, so-called cardiac autonomic balance index) and low
standard deviation of HR (SDHR) along with high electrodermal activity (skin conductance level -SCL) were good
indicators of excessive sympathetic and reduced parasympathetic activation at the pre-treatment stage (58). Results
of the study showed that, except for a reduction in LF
power of HRV, all dependent HRV variables changed in the
predicted way (decreased heart rate, increased standard
deviation of HR, increase of HF of HRV, decreased SCL).
Besides the DLPC other areas of the brain have been
stimulated with improved performance in behavioural tasks
in ASD individuals. Fecteau and colleges applied a single
session of rTMS (1 Hz) to the left and right pars triangularis
and pars opercularis in 10 individuals with ASD and 10
matched neurotypicals (59). Compared to the sham controls, all ASD individuals showed reduced latency to name
objects on the Boston Naming test. A similar study using a
single session of 1 HZ rTMS was applied to the left primary
motor region (M1) and the supplementary motor area
(SMA) in 11 individuals with ASD (60). Activation of the
sensorimotor system while observing another person’s
actions is referred to as interpersonal motor resonance
and is considered an index of mirror neuron activity. The
study reported significant improvements in late movement
related cortical potential (MRCP) following stimulation
of M1 and of the early MCRP following stimulation of
the SMA.
In summary, contrary with clinical interventions that
target behavioural manifestations of ASD, TMS focuses on
what may be considered a core pathology of the condition,
that is, a minicolumnopathy that manifests marked deficits
of lateral inhibition. It is the only intervention for ASD
that has shown improvements in executive functions as
evidenced by normalisation of ERP responses, reaction

Autism and TMS

time and accuracy during tests of executive function.
Although applied primarily to the DLPC, the effects,
according to behavioural performance and electrophysiology, are not limited to this region. Contrary with other
interventions, repetitive pulse TMS is fairly safe and offers
few side effects to treatment, e.g. a transient tension type
headache, discomfort due to the sound of the pulses. Many
clinical trials have been performed in children attesting
to both its safety and efficacy. Future studies should
address the long-term effectiveness of the technique and
the possible synergism when used in conjunction with
behavioural and pharmacological therapies in larger
sample sizes.

ACKNOWLEDGEMENTS
This article is based on several studies partially supported
by a grant from the National Institutes of Health
(MH86784) awarded to Manuel F. Casanova.

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