Bringing Transcranial Magnetic Stimulation to Pediatric Care

Cincinnati Children’s is expanding access to transcranial magnetic stimulation (TMS) for adolescents with depression—building on decades of pediatric research and establishing one of the nation’s few programs focused primarily on young patients.

In the spring of 2024, the FDA cleared the first TMS devices for use in adolescents ages 15 and older who have depression that doesn’t improve enough with medication, or who can’t tolerate a medication side effect. Within months, Cincinnati Children’s launched an interventional psychiatry program, including a dedicated TMS center. To date, the center has treated close to 30 pediatric patients.

“We were uniquely positioned to start right away,” says Rana Elmaghraby, MD, the center’s medical director and a psychiatrist in Cincinnati Children’s Division of Child and Adolescent Psychiatry. “That’s not only because we already had two TMS devices approved for treatment in adults, one of which came through a generous gift from the Cincinnati Children’s Gift Shop/Junior Co-operative Society, but because of the decades of work our researchers had performed in this space to demonstrate TMS’ safety and efficacy in a pediatric patient population.”

Building on a Cornerstone of Research

Elmaghraby points to research conducted since 2001 by pediatric psychiatrist Ernest Pedapati, MD, MS, and pediatric neurologists Donald Gilbert, MD, MS, and Steve Wu, MD, in Cincinnati Children’s TMS Lab as the foundation for the center. The lab is one of the first in the country to use TMS technology to study child and adolescent brain function. Treatment became an area of focus after the FDA cleared TMS devices for use in adult patients with depression in 2008.

“Their work and expertise helped pave the way for us to use TMS to treat pediatric patients,” Elmaghraby says.

A donation from the Convalescent Hospital Fund for Children helped make the interventional psychiatry program—and the TMS center—a reality.

A Mid-Level Option for Families

For families of adolescents with depression, TMS provides a noninvasive, outpatient option that doesn’t come with the side effects often associated with medications.

“Families have been desperate for a new avenue when their child is not responding to medications or therapy,” Elmaghraby says. “We are glad that we can now offer TMS as this new treatment option.”

Kelli Dominick, MD, PhD, director of the interventional psychiatry program and a psychiatrist in the Division of Child and Adolescent Psychiatry, says most adolescents respond to TMS treatment, with up to 70% seeing improvement and 30% to 40% achieving full remission.

TMS sessions are tailored to each patient. After a comprehensive evaluation, patients undergo a mapping session to determine stimulation levels and brain targets. Treatment schedules vary, with some adolescents completing therapy in as little as a few weeks using accelerated protocols.

A Pediatric and Neurodevelopmental Focus

While other health systems offer TMS programs, most primarily serve adults. Cincinnati Children’s is one of the first in the region to focus specifically on pediatric patients—and among only a few nationally with expertise in treating adolescents and young adults with neurodevelopmental disorders.

“We are very comfortable treating depression in patients with autism, Fragile X syndrome and other genetic disorders,” Elmaghraby says. “Some providers shy away from treating that patient population. But we’ve treated them successfully with minimal side effects, and they’ve had incredible improvements.”

Approximately 40% to 50% of patients treated so far have had a co-occurring neurodevelopmental condition, she says. The center’s multidisciplinary team includes psychiatry, neurology, advanced practice providers and nurses, allowing for coordinated care of medically complex patients.

The center also offers both standard TMS and deep TMS, expanding protocol options for different patient needs.

Forward-Looking Plans

After an initial internal pilot, Cincinnati Children’s recently began accepting external referrals through the interventional psychiatry referral system.

“We want families to have options early on, before depression really affects functionality and well-being,” Elmaghraby says.

The team is also preparing to expand services to include obsessive-compulsive disorder treatment for young adults, as FDA clearance currently applies to patients ages 18 and older. At the same time, Cincinnati Children’s is developing a training curriculum to help other pediatric providers implement TMS safely in pediatric patient populations.