Precision Functional Mapping-Guided Neuromodulation in Minimally Speaking Youth: The Neuro-Accommodation Protocol
DOI: Pending DOI
Synopsis
Neuroimaging advances our knowledge regarding autism brain mechanisms, and neuromodulation provides a promising rehabilitation avenue; however, minimally speaking autistic individuals are often excluded. We developed the Neuro-Accommodation Protocol (NAP) to prepare individuals with higher support needs for precision functional mapping (PFM) and individualized, targeted neuromodulation. NAP is a novel, multi-module program that initiates with home-based visual modeling guides and gradual exposure, followed by on-site mock scanner practice and still-training, concluding with the actual MRI. This framework aims to decrease anxiety and shape the behavioral skills required for both PFM of MRI data collection and subsequent neuromodulation. Establishing this protocol, NAP enables safe, high-fidelity data acquisition and individualized neurorehabilitation.
Background
25% to 35% of persons with autism are minimally speaking individuals (MSIs) [1-5], but they have been largely excluded in neuroimaging and neuromodulation research and clinical care delivery with these technologies [6]. Existing clinical and cognitive protocols rely on verbal communication [7-8] and average or above intellectual functioning. Consequently, there is a substantial gap in understanding the neural mechanisms underlying language and communication in MSI. Additionally, some fMRI studies [9] use sedation, exposing participants to physical risks and altering neurophysiology during functional image acquisition. High variability in individual brain network topography is posited to contribute to variable effects of neuromodulation, and individual functional network maps generated via PFM permit more precise engagement of an individual’s unique neural circuitry using noninvasive brain stimulation techniques. Furthermore, current large datasets have limited low-motion fMRI data (typically around 5-8 minutes per participant) which is insufficient for identifying reliable functional topography maps to guide individually targeted neuromodulation. We are developing NAP as an inclusive, behavioral strategy for populations with high support needs, including MSI, to facilitate high-fidelity MRI data collection as a robust prerequisite for individualized precision neuromodulation.
Methods
We aim to collect 50 minutes of low-motion resting-state fMRI data from three MSIs with autism aged 11 to 17 years. Here, “minimally speaking” refers to individuals who use spoken language at the level of single words at most (no word combinations). Participants will have a formal diagnosis of autism spectrum disorder, excluding those with a history of epilepsy or metallic cranial implants. Functional topography maps will be compared between MSI and a sex-matched, age-approximated cohort from the Adolescent Brain Cognitive Development (ABCD) Study to identify deviations in speech-related networks. To facilitate compliance and accessibility, we designed NAP as a multi-setting desensitization protocol providing cognitive, sensory, and physical accessibility to advance neuroimaging and neurorehabilitation. The home kit module contains visual supports, checklists, and social stories. Caregivers receive remote training to implement brief, structured, gradual exposure sessions using these materials, including a mock head coil and its cushion. After achieving home-based readiness, participants practice in an on-site mock scanner before the actual MRI. These same desensitization principles are designed to map onto the sensory and physical demands related to neuromodulation. Diverse clinical, cognitive, behavioral, and communication assessments are conducted to generate a comprehensive profile for each participant.
Results
As the protocol nears finalization, the primary anticipated outcome is the successful acquisition of 50 minutes of low-motion, high-fidelity PFM data to identify individual functional topography maps in MSI youth. By utilizing NAP and monitoring in-scanner motion tracking (FIRMM software) with in-scan feedback, we expect a quantifiable decrease in motion (tracked via caregiver checklists recording stillness duration at home and in-scanner via FIRMM framewise displacement). The home-based component comprising visual supports, checklists, and a mock head coil is guided under telehealth training. Leveraging multidisciplinary team expertise, we aim to establish high fidelity individualized precision neuroimaging, without sedation, for groups who have been highly excluded. This pilot establishes the preliminary behavioral compliance necessary for subsequent neuromodulation targets. These outcomes serve as a proof-of-concept that advanced imaging and neurorehabilitation interventions can be feasible for MSI by providing accessible, individualized accommodations.
Discussion
Current neuroimaging findings are not generalizable to all individuals with autism given the exclusion of those who are minimally speaking or have lower cognitive abilities (IQ < 70). NAP is designed to mitigate these traditional obstacles, making neuroimaging and neuromodulation accessible to this population. Implementing customized, multi-sensory multi-setting accommodation procedures can provide equitable, inclusive opportunities within advanced translational science. For clinical practice and future neuromodulation research, this protocol aims to demonstrate that precision targeting is achievable in populations with high support needs. The current NAP module provides MRI compliance for precision neuromapping; however, additional ongoing efforts are extending these accommodations to the neuromodulation environment and procedures. This initial phase is a pilot feasibility study and establishes a rigorous methodological foundation, and provides data and input from investigators, MSI, and their parents/caregivers for further NAP model development. Successful implementation of this foundational phase of NAP will establish a gateway clinical service model to allow individuals who need significant medical support to ultimately access cutting-edge individualized therapeutics.
Disclosures
This project is funded by the MIDB Seed Grant (1751-11861-20089-X-X-X-8016120). Nothing to disclose by any author(s).
References
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