Neurodevelopmental considerations for transcranial magnetic stimulation trials in youth

Repetitive transcranial magnetic stimulation (rTMS) is an emerging treatment for neuropsychiatric disorders that shows initial efficacy, safety, and tolerability in adolescents with treatment-resistant depression. As research expands to clinical trials testing rTMS in youth with other diagnoses and at younger ages, it is important to consider how neurodevelopmental factors might moderate or mediate rTMS effects and factor this into clinical trial design. In the current paper, we review how key domains of neurodevelopment may interact with rTMS, including neuroanatomy, neural circuit network topography, neuroplasticity, hormones, state-dependent effects, and psychosocial development. We also highlight approaches that can be taken in trials to enhance developmental adaptations of rTMS while also balancing ethical considerations, safety, feasibility, and tolerability. Future directions for research as we move into the "efficacy era" of pediatric rTMS research are discussed.