Modulation of Frontoparietal Dynamics Underlying Adolescent Working Memory Deficits

Modulation of Frontoparietal Dynamics Underlying Adolescent Working Memory Deficits: A COBRE Pilot Project

The purpose of this study is to test whether a single session of brain stimulation (called repetitive transcranial magnetic stimulation [rTMS]) can improve the brain activity underlying 'working memory.' Working memory is the ability to hold information 'in mind' to complete daily activities. This study involves teenagers with ADHD as well as healthy young adults. It is funded by The COBRE Center for Neuromodulation (CCN) at Butler Hospital (Pilot Project)

Study Overview

• Status: Recruiting
• Conditions: ADHD
• Intervention / Treatment: Device: Intermittent Theta Burst Stimulation

Detailed Description

The objective of this project is to examine the contributing roles of the PPC and PFC in WM processes and relatedly, develop optimal targets for modulating WM-related neural oscillations. Patient Arm: In a 2x2 factorial double-blind design, we will randomize a sample of adolescents (13-18 years) with WM deficits to intermittent theta burst stimulation (iTBS) at the left dorsolateral prefrontal cortex (DLPFC) or inferior parietal lobule (IPL), based on each participant's structural brain MRI. Control Arm: A sample of healthy young adults (18-25 years) will receive an individualized theta-gamma parameters protocol of iTBS to the left DLPFC. Participants in both arms will complete an active iTBS session and a sham iTBS session. The primary outcome will be theta-gamma coupling during WM demands, as measured via electroencephalography (EEG) during a Sternberg spatial WM task (SWMT) immediately before and after iTBS. The central hypothesis is that the PFC and PPC regions have complimentary roles in executing WM processes. Further, iTBS can modulate theta-gamma coupling in these regions to improve behavioral performance. Our central hypothesis is formulated based on our preliminary data on the critical role of theta-gamma coupling in WM processes. To attain the overall objectives, the following specific aims will be pursued:

Aim 1: Examine the effect of iTBS to the PPC on the encoding stage of WM. Hypothesis: Compared to sham and DLPFC conditions, iTBS to the IPL will increase theta-gamma coupling during encoding. Modulation of theta-gamma coupling will correlate with improved behavioral performance.

Aim 2: Examine the effect of iTBS to the PFC on the maintenance stage of WM. Hypothesis: Compared to sham and IPL conditions, iTBS to the DLPFC will increase theta-gamma coupling during maintenance. Modulation of theta-gamma coupling will correlate with improved behavioral performance.

Aim 3: Examine the feasibility and preliminary effect of individualized iTBS to the PFC. Hypothesis: It will be feasible to utilize peak theta-gamma coupling during the SWMT to identify optimal iTBS parameters. Individualized iTBS will increase theta-gamma coupling during WM demands and improve behavioral performance.

Exploratory Aim: Identify the neocortical circuitry underlying oscillatory modulation. Computational modeling designed for neural interpretation of EEG will translate obtained recordings into cellular/circuit-level activity delineating the neural mechanism of the observed modulation. Hypothesis: pyramidal-interneuron mechanisms within the PPC/PFC will underlie the theta/gamma oscillatory modulation.

• Study Type: Interventional
• Enrollment (Estimated): 25
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Brian C Kavanaugh, PsyD ABPP; Phone Number: 401 432 1359; Email: Bkavanaugh@Lifespan.org

Study Locations

• United States
  • Rhode Island
    • East Providence, Rhode Island, United States, 02915
      • Recruiting
      • E. P. Bradley Hospital
      • Contact: Brian C Kavanaugh, PsyD ABPP; Phone Number: 401-432-1359; Email: Bkavanaugh@lifespan.org

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 13 years to 25 years (Child, Adult)
• Accepts Healthy Volunteers: Yes

Description

Patient Arm: We will enroll a sample of adolescents (age 13-18 years) with working memory deficits and ADHD. Participation in this study will not require any adjustments to their clinical care. There are no costs to this study (participants compensated) and there are no expected long-term benefits to the participants. Participants will be compensated for each session. Participants can withdraw from the study at any time.

Inclusion Criteria

1. Ability to provide assent and have parent provide parental permission
2. English fluency of the participant and the legal guardian/parent
3. 13-18 years
4. Parent rating on BRIEF-2 Working Memory: Greater than 1.0 SD above normative mean.
5. IQ > 80
6. Clinical diagnosis of attention deficit hyperactivity disorder (ADHD): predominantly inattentive type, predominantly hyperactive/impulsive type, combined type, or unspecified type. Diagnostic criteria will be confirmed with NICHQ Vanderbilt Assessment Scales-Parent.

Healthy Control Arm: We will target a sample of healthy, young adults. Inclusion Criteria

1. Ability to provide consent
2. English fluency of the participant
3. 18-25 years
4. Never diagnosed or meets current criteria for a psychiatric disorder, as measured by self-report of prior diagnoses and formal completion of the diagnostic interview.

Exclusion Criteria: For patient and healthy control participants

Participants will be screened to exclude individuals with neurological or medical conditions that might confound the results, as well as to exclude participants in whom MRI or TMS might result in increased risk of side effects or complications. Common contraindications include metallic hardware in the body, cardiac pacemaker, patients with an implanted medication pumps or an intracardiac line, or prescription of medications known to lower seizure threshold. These account for the majority of the exclusion criteria listed below:

1. Intracranial pathology from a known genetic disorder (e.g., NF1, tuberous sclerosis) or from acquired neurologic disease (e.g. stroke, tumor), cerebral palsy, history of severe head injury, or significant dysmorphology
2. History of fainting spells of unknown or undetermined etiology that might constitute seizures
3. History of seizures, diagnosis of epilepsy, or immediate (1st degree relative) family history epilepsy
4. Any progressive (e.g., neurodegenerative) neurological disorder
5. Chronic (particularly) uncontrolled medical conditions that may cause a medical emergency in case of a provoked seizure (cardiac malformation, cardiac dysrhythmia, asthma, etc.)
6. Contraindicated metal implants in the head, brain or spinal cord (excluding dental implants, braces or fillings)
7. Non-removable makeup or piercings
8. Pacemaker
9. Implanted medication pump
10. Vagal nerve stimulator
11. Deep brain stimulator
12. TENS unit (unless removed completely for the study)
13. Ventriculo-peritoneal shunt
14. Signs of increased intracranial pressure
15. Intracranial lesion (including incidental finding on MRI)
16. History of head injury resulting in prolonged loss of consciousness
17. Substance abuse or dependence within past six months (i.e., DSM-5 substance use disorder criteria)
18. Chronic treatment with prescription medications that decrease cortical seizure threshold, not including psychostimulant medication if deemed to be medically safe as part of the medical review process.
19. Active psychosis or mania
20. Current suicidal intent
21. Current pregnancy
22. Significant visual, hearing or speech impairment
23. Current wards of the state

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Basic Science
• Allocation: Randomized
• Interventional Model: Crossover Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Patient Arm; In a 2x2 factorial double-blind design, we will randomize a sample of adolescents (13-18 years) with WM deficits to intermittent theta burst stimulation (iTBS) at the left dorsolateral prefrontal cortex (DLPFC) or inferior parietal lobule (IPL), based on each participant's structural brain MRI. Participants in both arms will complete an active iTBS session and a sham iTBS session. The primary outcome will be theta-gamma coupling during WM demands, as measured via electroencephalography (EEG) during a Sternberg spatial WM task (SWMT) immediately before and after iTBS.	Device: Intermittent Theta Burst Stimulation; iTBS
Experimental: Healthy Control Arm; Control Arm: A sample of healthy young adults (18-25 years) will receive an individualized theta-gamma parameters protocol of iTBS to the left DLPFC. Participants in both arms will complete an active iTBS session and a sham iTBS session. The primary outcome will be theta-gamma coupling during WM demands, as measured via electroencephalography (EEG) during a Sternberg spatial WM task (SWMT) immediately before and after iTBS.	Device: Intermittent Theta Burst Stimulation; iTBS

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Theta-Gamma Coupling After Sham iTBS	EEG recording will be obtained while the participant completes the Sternberg Spatial Working Memory Test (SWMT). The coupling between theta phase and gamma amplitude will be extracted from the EEG during encoding and maintaining demands. The change between pre and post a single iTBS session will be calculated.	Theta-gamma coupling will be obtained before and after iTBS administration. There will be approximately 5 minutes between the pre and post EEG recordings. The change between pre and post is the outcome variable.
Change in Theta-Gamma Coupling after Active iTBS	EEG recording will be obtained while the participant completes the Sternberg Spatial Working Memory Test (SWMT). The coupling between theta phase and gamma amplitude will be extracted from the EEG during encoding and maintaining demands. The change between pre and post a single iTBS session will be calculated.	Theta-gamma coupling will be obtained before and after iTBS administration. There will be approximately 5 minutes between the pre and post EEG recordings. The change between pre and post is the outcome variable.

Collaborators and Investigators

• Sponsor: Bradley Hospital
• Collaborators: Funding Source: COBRE Center for Neuromodulation at Butler Hospital (Pilot Project)

Study record dates

Study Major Dates

• Study Start (Actual): October 1, 2021
• Primary Completion (Estimated): March 30, 2024
• Study Completion (Estimated): March 30, 2024

Study Registration Dates

• First Submitted: October 6, 2021
• First Submitted That Met QC Criteria: November 2, 2021
• First Posted (Actual): November 15, 2021

Study Record Updates

• Last Update Posted (Actual): September 28, 2023
• Last Update Submitted That Met QC Criteria: September 26, 2023
• Last Verified: October 1, 2022

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Nervous System Diseases; Neurologic Manifestations; Neurobehavioral Manifestations; Memory Disorders
• Other Study ID Numbers: BradleyH002

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: Yes