Skip to main content
  • Study Protocol
  • Open access
  • Published:

An open-label prospective pilot trial of nucleus accumbens deep brain stimulation for children with autism spectrum disorder and severe, refractory self-injurious behavior: study protocol



Children and youth with autism spectrum disorder (ASD) may manifest self-injurious behaviors (SIB) that may become severe and refractory with limited pharmacologic or behavioral treatment options. Here, we present the protocol of a prospective, mixed-methods study to assess the safety and efficacy of deep brain stimulation (DBS) of the nucleus accumbens (NAcc) for children and youth with ASD and severe, refractory SIB.


This is a prospective, single-center, single-cohort, open-label, non-randomized pilot trial of 6 patients. Participants will be recruited through specialized behavioral clinics with persistent severe and refractory SIB following standard and intensive interventions. Following NAcc-DBS, participants will be enrolled in the study for 12 months. The primary objectives of the study are safety and feasibility, assessed by rate of recruitment and identification of factors impacting adherence to follow-up and study protocol. Potential treatment efficacy will be assessed by changes in the Children’s Yale-Brown Obsessive-Compulsive Scale in ASD (CYBOCS-ASD), the Behavior Problems Index (BPI), the Inventory of Statements about Self-Injury (ISAS) and the Repetitive Behavior Scale-Revised (RBS-R) questionnaires. Additional clinical outcomes will be assessed, including measures of participant and caregiver quality of life, actigraph measurements, and positron emission tomography (PET) changes following DBS.


This study will be the first to evaluate the effect of DBS of the NAcc on a pediatric population in a controlled, prospective trial. Secondary outcomes will improve the understanding of behavioral, neuro-imaging, and electrophysiologic changes in children with ASD and SIB treated with DBS. This trial will provide an estimated effect size of NAcc-DBS for severe refractory SIB in children with ASD in preparation for future comparative trials.

Trial registration

Registration on was completed on 12 June 2019 with the Identifier: NCT03982888.

Peer Review reports


Autism spectrum disorder (ASD) is a clinical diagnosis based on a set of heterogeneous neurodevelopmental conditions. ASD is characterized by difficulties in social interaction, communication, repetitive restricted behaviors according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) [1]. ASD has a worldwide prevalence of 1%, an estimated 1 in 68 births in the USA in 2014 by the Center for Disease Control and Prevention, and a greater prevalence in males than females [2,3,4].

The behavioral comorbidities of ASD include aggressive behavior (up to 68%) [5, 6] and repetitive self-injurious behavior (up to 50%) [7, 8]. In children with ASD and self-injurious behaviors (SIB), over 75% of children will have persistence of these behaviors into adulthood, sometimes resulting in severe harm and even death [5, 9,10,11]. SIB can be defined as repetitive “behavior which produces physical injury to the individual’s own body” with several different subclassifications [12]. Pharmacologic agents, such as antipsychotics (e.g., risperidone, aripiprazole), and selective serotonin reuptake inhibitors (e.g., fluoxetine) show evidence for treating irritability but not specifically reducing self-injury [13,14,15,16,17].

Applied behavior analysis, based on operant methodology, offers an evidence-based method to assess and treat SIB. Functional analysis identifies the function of the behavior and shows what conditions self-injury are associated with and what stimulus conditions maintain it [18]. It is hypothesized that social consequences, such as escape from demands or selective attention, mediate 20–25% of SIB through automatic reinforcement [12, 19]. Subtypes of automatic reinforcement show differential responses to reinforcement-based interventions and may have implications on the biological bases of SIB and biobehavioral research. This may also give us insight into the role of neuromodulation as a feasible intervention for SIB.

Neuromodulation, through deep brain stimulation (DBS), may present novel treatment options for this population when other treatments are not effective or tolerated. DBS is a precise neuromodulation strategy for targeting pathological brain circuitry [20], albeit with incompletely understood mechanisms of action. DBS involves implantation of electrodes (often two with one on each side of the brain) into deep brain targets and delivery of an electrical current through these electrodes via an impulse generator implanted in the chest. The indication for DBS in pediatric populations is primarily for dystonia, notably inherited dystonia without nervous system pathology [21]. In children with refractory disease processes, DBS has been previously utilized for novel indications, such as select cases of Tourette’s syndrome, obsessive-compulsive disorder (OCD), and epilepsy with varying levels of success [22,23,24,25,26]. In the course of DBS treatment for dystonia and Tourette’s syndrome in adult patients with comorbid SIB, reduction in the frequency or full cessation of SIB has been reported [27, 28]. DBS of several targets has previously been employed to treat SIB, including in six patients under the age of 20 with ASD (Table 1). These targets include the basolateral amygdala [30], globus pallidus internus [31], posterior hypothalamus [32], and the nucleus accumbens (NAcc) [34].

Table 1 Literature review of DBS for the treatment of SIB and ASD

The NAcc of the ventral striatum receives projections from the orbitofrontal cortex and sends hierarchical information via spiraling striatonigrostriatal projections to the dorsal striatum [36, 37]. Volumetric studies of the striatum suggest that an imbalance of the ventral-dorsal striatal circuity may underlie SIB [38, 39]. Likewise, the amygdala, a previous target for SIB in children also projects widely to the striatum, with weaker connectivity patterns in children with ASD [40]. The NAcc also possesses widespread projections to the dopaminergic receptors of the ventral tegmental area [36]. Other pathologies, such as OCD, addiction, and alcoholism, have been treated with NAcc-DBS [41,42,43,44]. When the NAcc is targeted for DBS, the anterior limb of the internal capsule (ALIC) can be stimulated simultaneously to augment behavioral changes related to attention and sensorimotor control.

Study design

We present a protocol for a single-center, single-cohort, open-label, non-randomized prospective pilot trial of NAcc-DBS for refractory and severe SIB in children with ASD. The trial is currently open for recruitment at the Hospital for Sick Children (HSC) in Toronto.

Goals and objectives

The primary objective of the study is to assess feasibility and safety, measured by recruitment rate, identification of factors impacting follow-up and protocol adherence, and successful implantation. Secondary clinical objectives include change in frequency or severity of SIB following surgery, measured regularly by caregiver-reported questionnaires over the course of 1 year. Additional clinical outcomes include changes quality of life for the patient and their caregiver(s), repetitive motion characteristics as measured with actigraphy, metabolic changes seen through positron emission tomography (PET), and changes on electrophysiologic data. To our knowledge, this is the first prospective trial of DBS for children with SIB and represents the first assessment of a potential surgical treatment for patients with extremely limited therapeutic options.


This is a prospective, single-center, open-label, non-randomized study of six patients at HSC. The aim is to evaluate the feasibility and safety of DBS of the NAcc for medically refractory, repetitive self-injurious behaviors in children with ASD. Electrophysiological parameters are optimized in the 12-month follow-up to study and manage possible side effects.

Ethics and registry

This research involves human participants and is performed in accordance with the Delcaration of Helsinki. This trial was approved by the Hospital for Sick Children Research Ethics Board, approval number 1000060282. Registration on was completed in June of 2019 with the Identifier: NCT03982888. Patient recruitment and continuation in the study is considered by a safety monitoring board at HSC. Written informed consent to participate in the trial is acquired from the child or adolescent when able, or the parent or legal guardians. If the child or adolescent is unable to provide consent, assent is sought.

Enrollment and surgery

Potential participants are recruited from specialized behavioral clinics. Potential participants are reviewed by the investigators with respect to inclusion and exclusion criteria (Table 2). Eligible patients are discussed in a multidisciplinary meeting of the surgical, psychiatric and medical teams. There are no changes to the participants’ medications or behavior therapies after enrollment prior to surgery. Any changes to medications following surgery are noted, including changes to dosages and indication for change.

Table 2 Study inclusion and exclusion criteria

Participants are assessed by the anesthesia service, neuropsychology team, and receive a magnetic resonance image (MRI) and optional fluorodeoxyglucose (FDG) PET scan. On the day of surgery, a Leksell stereotactic frame is applied under general anesthesia. The patient receives a head computed tomography (CT) scan that is merged to the pre-operative MRI and planned targets. Stereotactic coordinates are calculated and verified to target the NAcc with the goal to include the ALIC in the trajectory of the DBS electrode (Fig. 1 B, C). In the operating room, a curvilinear incision anterior to the coronal suture is made to place the DBS electrodes stereotactically. Thresholds for side effects are recorded intraoperatively. Electrodes are placed with fluoroscopic confirmation and a pulse generator is connected and implanted in the infraclavicular region under the same anesthetic.

Fig. 1
figure 1

DBS for children, targeting the NAcc. A DBS extension wires for children are placed with greater length to allow for growth. B Coronal representation of DBS lead trajectory, passing through the ALIC and targeting the NAcc. C 3D representation of DBS lead trajectory. NAcc (purple), ALIC (yellow), caudate (dark blue), putamen (light blue), and globus pallidus (green)

Patients undergo a postoperative MRI to confirm the position of the electrodes. After the surgery, they are monitored in the hospital for 3–5 days and discharged with the stimulator off. Patients start DBS programming at 4–6 weeks after surgery and visit the joint neurosurgery, neurology DBS clinic at HSC. There is regular monitoring for the development of behavioral, motor, and psychiatric effects from stimulation. During weeks 2–6, there are weekly follow-ups to address any potential complications. The full schedule of events is presented in Table 3.

Table 3 Follow-up schedule for trial participan ts

Sample size and recruitment

In this prospective, controlled trial, six patients are selected to determine safety and initial potential efficacy, as it typical for most DBS early phase trials. There is no control group, and each patient will serve as a comparator for primary outcome measures.

Feasibility and safety

The trial will be determined feasible if there is > 50% recruitment rate or recruitment of 6 patients in under 36 months as a threshold for progression to a definitive trial. Recruitment rate is measured as the ratio of participants enrolled compared to those who are eligible. New DBS targets typically include 6 patients in pilot trials [45, 46] to establish an initial understanding of effect of therapy through multiple outcomes: clinical, radiographic, and electrophysiologic. There will be additional secondary feasibility outcomes with projected thresholds to determine achievability. These include the proportion of patients who received surgery following enrollment (80%), proportion of patients with full completion of baseline questionnaires (90%), proportion of patients with full completion of multi-modal outcome assessments (i.e., PET, actigraphy) (50%), and percent completion of all clinical outcome data (80%). Families unable to speak English will complete questionnaires through the aid of translators and their completion rate of outcome measures will be compared to English speakers. These data will provide additional information regarding decision-making of progression to a large trial. Any deviance to study protocol or inability to complete clinical questionnaires will be documented with an attempt to understand patient barriers.

The measure of safety outcomes is critical as this routine procedure is being implemented in a new patient population for a novel indication. Immediately peri-operatively in hospital, neurologic complications from surgery (bleeding, seizure) will be monitored and recorded. Longitudinal safety of the intervention will be carefully monitored with weekly phone calls to participants for the first 6 weeks. Participants will be monitored for post-operative complications (i.e., hardware malfunction, signs of infection, unexpected neurologic symptoms) and worsening of severity or frequency of self-injurious behaviors. The expected complication rate is < 10%.

There is no official Data and Safety Monitoring Board (DSMB) for this pilot. Instead, a safety subcommittee consisting of a neurosurgeon, a neurologist, and a developmental pediatrician will meet twice annually to discuss possible safety concerns. This committee would help with the design of the future definitive trial based on the safety concerns raised during this pilot. There are no current stopping criteria outlined, but the safety subcommittee would have the authority to determine cessation of the trial due to unexpected safety concerns.

Clinical outcome measures

This trial will conduct pre-post analyses to compare frequency and severity of SIB in children and youth with ASD before and after DBS intervention. Clinical outcomes are measured by the change between baseline and 1 year in the following validated scales: Children’s Yale-Brown Obsessive-Compulsive Scale in Autism Spectrum Disorder (CYBOCS-ASD) [47, 48], the Behavior Problems Inventory (BPI) [49], the Inventory of Statements about Self-Injury (ISAS) [50] and the Repetitive Behavior Scale-Revised (RBS-R) [51]. These scales were chosen by expert consensus between developmental pediatricians, neurologists, and the neurosurgical team. Although no scale has specifically been validated for children with ASD and SIB, the combination of these scales studied in children with ASD or all-age patients with repetitive behavior will provide an assessment of responsiveness of DBS over time. Secondary clinical outcomes are measured using the Quality of Life Scale 9Peds QL version 4, Aberrant Behavior Checklist [52, 53], and caregiver logs of repetitive self-injurious behaviors. Time to complete each questionnaire and correlation with quality of life will be useful information in the design of a composite primary objective in larger, future trials.

Patients and caregivers complete scales prior to the intervention and also at week 4, 12, week 26, and week 52. Baseline assessments are completed prior to surgery. Efficacy is determined by the within-subject percent change in the primary outcome scores at 1 year (week 52) following surgery compared to baseline.

Additional outcomes include changes in motor patterns based on actigraphy. Actigraphy is the continuous measurement of an individuals’ movement using a device worn similarly to a watch (Axivity AX3 and Axivity AX6) [54, 55]. The Axivity device can quantify movements and has been validated to detect specific behaviors, such as hand flapping, of patients with ASD with 94.6% accuracy [56]. Children have an actigraph placed on their non-dominant wrist 4 weeks prior to the surgery for a total of 2 weeks of recordings. During specific follow-up visits (weeks 12, 26, and 52), the children have the option to wear the actigraph for 2-week intervals. Markers of stereotypies include maximum and minimum value amplitudes, variance, peak to peak, and entropy fast Fourier transform, to be analyzed using MATLAB (Mathworks, Natick, MA) [54, 56].

Children enrolled in the trial may receive a FDG-PET scan prior to surgery, and 12 months after surgery. PET scanning is optional and for research purposes only, which will be disclosed to all participants. PET scans of pediatric patients with anorexia who received NAcc-DBS has demonstrated the reversal of metabolic abnormalities, such as hypermetabolism in the frontal lobes, hippocampus, and lentiform nucleus [57]. The FDG-PET of participants in the present study may similarly demonstrate changes of metabolism in the brain following NAcc-DBS.


Evaluation and assessments occur at approximately 22 time points from pre- to 1-year post-surgery (Table 3). Participants are followed weekly after surgery by the medical team between weeks 0–6, and monthly after 8 weeks. There are two required MRI scans that fall under the standard of care, two optional FDG-PET scans, and 3 possible 2-week periods of actigraph recordings. Surveys for the primary clinical outcomes and secondary outcomes are administered once prior to the surgery and four times following surgery. DBS programming starts at approximately 4–6 weeks and reassessment and stimulation changes are planned for weeks 12, 26, and 52 unless there are adverse effects, for which there will be additional programming visits. Ongoing follow-up for safety and DBS programming will occur at HSC until participants turn 18 years old, at which point they will be transitioned to adult care.

Data management and statistical analysis

Patient information will be kept strictly confidential at all times, and all files related to this study will be password protected and kept on a password protected computer. Patient and caregivers will complete surveys and questionnaires online via a secure email link or on paper. The research team will check the content and completion of the forms monthly. All data will be kept for 25 years following the conclusion of the trial.

This is not a blinded study and all investigators and patients are aware of treatment. There is not blinded stimulation-off or stimulation-on periods after DBS implantation. Recruitment rates will be calculated monthly; the secondary feasibility and safety outcomes would be reported as proportions. Change in SIB and adverse effects will be analyzed longitudinally using comparative statistics. Repeated measures ANOVA and mixed-effects linear regression are used for analysis of clinical measures and changes over the course of 12 months. All efforts are made to reduce missing data with retrospective review and multiple imputation will be employed for unfound data.


The current paper presents a single-cohort, open-label, non-randomized, prospective pilot trial for the first controlled study of DBS of the NAcc for severe, refractory SIB in children and youth with ASD. This study is important to understand feasibility, safety, and treatment response. It is critical to establish feasibility of DBS for this novel indication and vulnerable patient population.

The rapid expansion of DBS indications in adult pathologies has allowed for treatment of many psychiatric diseases [58,59,60]. It is expected that the adaptation of DBS for children will be feasible for SIB. The early treatment of SIB in childhood could potentially be beneficial during critical windows of development such as in the adolescent or young adult years. The largest feasibility challenge of this study will be recruitment of vulnerable participants. This is mitigated by a multi-disciplinary team who are familiar with the patient population and the trial to allow for multiple sources of referral. Furthermore, results of a pilot trial should greatly improve recruitment in a future definitive trial. The use of multiple clinical measurement tools may help determine the optional composite measure of responsiveness of SIB to DBS. Although the quantitative data may not be rigorous enough to calculate a minimally clinical important difference, an estimated effect size may help determine sample size. Careful measurement and analysis of feasibility in this unique trial will be critical in the design of future research.

SIB has a high prevalence in several genetic disorders, such as Lesch-Nyhan disease and Fragile X syndrome, suggesting the pathophysiology of SIB may at least in part be rooted in neurobiological as well as neurodevelopmental etiologies [6]. Conversely, environmental triggers, such as novel sensory stimuli or changes in routine, often trigger the onset of episodes of SIB [61]. In patients with ASD, SIB frequency has a direct correlation with ASD severity [62]. The phenotype of SIB in patients with ASD shares similar features to phenotypic behaviors in other psychiatric conditions affecting children and adults, including OCD, attention-deficit hyperactivity disorder, and Tourette’s syndrome [63]. These conditions may be comorbid and share a common behavioral phenotype characterized by repetition, rigidity, invariance, and sometimes inappropriateness [38, 63]. Improved understanding of neural circuitry and effective DBS treatment options for one indication may enrich the understanding of the related diagnoses and their neurobiological pathophysiology.

DBS is a minimally invasive surgical option for patients with refractory SIB. It is reversible, adjustable and has a well-tolerated safety profile. Although increasingly offered to children for expanding indications, it is often considered an experimental therapy in this context. A proposed ethical framework to guide the conduct of DBS in children has been proposed, to which this study adheres [64]. The principles of this framework include viewing outcomes in a developmentally relevant context, cautiously applying adult data, and weighing the timing of the procedure [64].

Adult data and experience regarding DBS are not directly applicable to children. As one example, most children will have surgery under general anesthesia, which may preclude microelectrode recordings. Second, stimulation settings are often adopted from adult literature, yet long-term effects for children are not yet fully understood [23]. Third, indications and decisions regarding timing for intervention are complicated in children as treatment decisions are made within the context of childhood development and disease natural history. For example, the natural history of Tourette’s syndrome is often to remit as children develop and therefore the indications for DBS in children are as-of-yet unknown [65, 66]. Finally, complications including infection, lead migration or wire fractures are probably higher in children [21] and side effects of DBS on the developing brain require further study. Moreover, these hardware-related adverse events may manifest differently in children and youth with ASD and repetitive or compulsive SIB, relative to other pediatric cohorts.

Strengths and limitations

This is a prospective, pilot trial of six patients and analyses of clinical outcomes will be limited by the small cohort. The results of this trial should inform larger clinical trials of multiple institutions. Furthermore, there is a lack of consensus regarding the ideal clinical assessment tool to measure the severity and frequency of SIB events. The use of the CYBOCS-ASD, ISAS and the RBS-R questionnaires incorporates several aspects of SIB such as repetitive movements, degree of harm, and impact on functional activities.


This trial has primary objectives to assess the feasibility and safety of DBS for SIB in children with ASD. Clinical outcomes are composed of the change in CYBOCS-ASD, ISAS and the RBS-R questionnaires. Additional outcomes include measures of participant and caregiver quality of life, actigraph measurements, PET changes, and electrophysiologic data. These data will inform the design and conduct of future investigations in this vulnerable population to deliver novel effective therapies.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to patient privacy given the small cohort but are available from the corresponding author on reasonable request.



Anterior limb of internal capsule


Autism spectrum disorder


Clinical Global Impairment-Severity


Computed tomography


Children’s Yale-Brown Obsessive-Compulsive Scale in Autism Spectrum Disorder


Deep brain stimulation


Diagnostic and Statistical Manual of Mental Disorders, 5th edition




Global assessment of functioning


Hamilton Anxiety Scale


Hamilton Depression Scale


Hospital for Sick Children


Inventory of Statements about Self-Injury


John’s Hopkins motor stereotypy rating scale


Korean ADHD Rating Scale


Magnetic resonance image


Nucleus accumbens


Overt Aggression Scale


Obsessive-compulsive disorder


Positron emission tomography


Repetitive Behavioral Scale-Revised


Social Communication Questionnaire


self-injurious behavior


Social Responsiveness Scale


Yale-Brown Obsessive-Compulsive Scale


  1. Lobar SL. DSM-V Changes for autism spectrum disorder (ASD): implications for diagnosis, management, and care coordination for children with ASDs. J Pediatr Health Care. 2016;30(4):359–65.

    Article  PubMed  Google Scholar 

  2. Lai MC, Lombardo MV, Baron-Cohen S. Autism. Lancet. 2014;383(9920):896–910.

    Article  PubMed  Google Scholar 

  3. Lai MC, Lombardo MV, Auyeung B, Chakrabarti B, Baron-Cohen S. Sex/gender differences and autism: setting the scene for future research. J Am Acad Child Adolesc Psychiatry. 2015;54(1):11–24.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Venker CE, Ray-Subramanian CE, Bolt DM, Ellis WS. Trajectories of autism severity in early childhood. J Autism Dev Disord. 2014;44(3):546–63.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Adler BA, Wink LK, Early M, Shaffer R, Minshawi N, McDougle CJ, et al. Drug-refractory aggression, self-injurious behavior, and severe tantrums in autism spectrum disorders: a chart review study. Autism. 2015;19(1):102–6.

    Article  PubMed  Google Scholar 

  6. Huisman S, Mulder P, Kuijk J, Kerstholt M, van Eeghen A, Leenders A, et al. Self-injurious behavior. Neurosci Biobehav Rev. 2018;84:483–91.

    Article  PubMed  Google Scholar 

  7. Baghdadli A, Pascal C, Grisi S, Aussilloux C. Risk factors for self-injurious behaviours among 222 young children with autistic disorders. J Intellect Disabil Res. 2003;47(Pt 8):622–7.

    Article  CAS  PubMed  Google Scholar 

  8. Sinha S, McGovern RA, Sheth SA. Deep brain stimulation for severe autism: from pathophysiology to procedure. Neurosurg Focus. 2015;38(6):E3.

    Article  PubMed  Google Scholar 

  9. Boser K, Higgins S, Fetherston A, Preissler MA, Gordon B. Semantic fields in low-functioning autism. J Autism Dev Disord. 2002;32(6):563–82.

    Article  PubMed  Google Scholar 

  10. Bradley V, Hiersteiner D, Rotholz D, Maloney J, Li H, Bonardi A, et al. Personal characteristics and outcomes of individuals with developmental disabilities who need support for self-injurious behaviour. J Intellect Disabil Res. 2018;62(12):1043–57.

    Article  CAS  PubMed  Google Scholar 

  11. Le JF, Lohr WD. Aggression and self-injury in a patient with severe autism. Pediatr Ann. 2012;41(10):1–3.

    PubMed  Google Scholar 

  12. Hagopian LP, Rooker GW, Zarcone JR. Delineating subtypes of self-injurious behavior maintained by automatic reinforcement. J Appl Behav Anal. 2015;48(3):523–43.

    Article  PubMed  Google Scholar 

  13. Malone RP, Waheed A. The role of antipsychotics in the management of behavioural symptoms in children and adolescents with autism. Drugs. 2009;69(5):535–48.

    Article  CAS  PubMed  Google Scholar 

  14. Sabus A, Feinstein J, Romani P, Goldson E, Blackmer A. Management of self-injurious behaviors in children with neurodevelopmental disorders: a pharmacotherapy overview. Pharmacotherapy. 2019;39(6):645–64.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Ricketts RW, Goza AB, Ellis CR, Singh YN, Singh NN, Cooke JC 3rd. Fluoxetine treatment of severe self-injury in young adults with mental retardation. J Am Acad Child Adolesc Psychiatry. 1993;32(4):865–9.

    Article  CAS  PubMed  Google Scholar 

  16. McCracken JT, McGough J, Shah B, Cronin P, Hong D, Aman MG, et al. Risperidone in children with autism and serious behavioral problems. N Engl J Med. 2002;347(5):314–21.

    Article  CAS  PubMed  Google Scholar 

  17. Lucchelli JP, Bertschy G. Low-dose fluoxetine in four children with autistic spectrum disorder improves self-injurious behavior, ADHD-like symptoms, and irritability. Case Rep Psychiatry. 2018;2018:6278501.

    PubMed  PubMed Central  Google Scholar 

  18. Iwata BA, Dorsey MF, Slifer KJ, Bauman KE, Richman GS. Toward a functional analysis of self-injury. J Appl Behav Anal. 1994;27(2):197–209.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Hagopian LP, Rooker GW, Zarcone JR, Bonner AC, Arevalo AR. Further analysis of subtypes of automatically reinforced SIB: a replication and quantitative analysis of published datasets. J Appl Behav Anal. 2017;50(1):48–66.

    Article  PubMed  Google Scholar 

  20. Miocinovic S, Somayajula S, Chitnis S, Vitek JL. History, applications, and mechanisms of deep brain stimulation. JAMA Neurol. 2013;70(2):163–71.

    Article  PubMed  Google Scholar 

  21. Elkaim LM, Alotaibi NM, Sigal A, Alotaibi HM, Lipsman N, Kalia SK, et al. Deep brain stimulation for pediatric dystonia: a meta-analysis with individual participant data. Dev Med Child Neurol. 2019;61(1):49–56.

    Article  PubMed  Google Scholar 

  22. Valentin A, Selway RP, Amarouche M, Mundil N, Ughratdar I, Ayoubian L, et al. Intracranial stimulation for children with epilepsy. Eur J Paediatr Neurol. 2017;21(1):223–31.

    Article  PubMed  Google Scholar 

  23. Marks WA, Honeycutt J, Acosta F, Reed M. Deep brain stimulation for pediatric movement disorders. Semin Pediatr Neurol. 2009;16(2):90–8.

    Article  PubMed  Google Scholar 

  24. Yan H, Toyota E, Anderson M, Abel TJ, Donner E, Kalia SK, et al. A systematic review of deep brain stimulation for the treatment of drug-resistant epilepsy in childhood. J Neurosurg Pediatr. 2018;23(3):274–84.

    Article  PubMed  Google Scholar 

  25. Testini P, Min HK, Bashir A, Lee KH. Deep Brain Stimulation for Tourette's Syndrome: The Case for Targeting the Thalamic Centromedian-Parafascicular Complex. Front Neurol. 2016;7:193.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Duarte-Batista P, Coelho M, Quintas S, Levy P, Castro Caldas A, Goncalves-Ferreira A, et al. Anterior Limb of internal capsule and bed nucleus of stria terminalis stimulation for Gilles de la Tourette Syndrome with obsessive-compulsive disorder in adolescence: A Case of Success. Stereotact Funct Neurosurg. 2020;98(2):95–103.

    Article  PubMed  Google Scholar 

  27. Cif L, Biolsi B, Gavarini S, Saux A, Robles SG, Tancu C, et al. Antero-ventral internal pallidum stimulation improves behavioral disorders in Lesch-Nyhan disease. Mov Disord. 2007;22(14):2126–9.

    Article  PubMed  Google Scholar 

  28. Houeto JL, Karachi C, Mallet L, Pillon B, Yelnik J, Mesnage V, et al. Tourette's syndrome and deep brain stimulation. J Neurol Neurosurg Psychiatry. 2005;76(7):992–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Kakko K, Bjelogrlic-Laakso N, Pihlakoski L, Lehtimaki K, Jarventausta K. Tardive Dyskinesia Should Not Be Overlooked. J Child Adolesc Psychopharmacol. 2019;29(1):72–4.

    Article  PubMed  Google Scholar 

  30. Sturm V, Fricke O, Buhrle CP, Lenartz D, Maarouf M, Treuer H, et al. DBS in the basolateral amygdala improves symptoms of autism and related self-injurious behavior: a case report and hypothesis on the pathogenesis of the disorder. Front Hum Neurosci. 2012;6:341.

    PubMed  Google Scholar 

  31. Stocco A, Baizabal-Carvallo JF. Deep brain stimulation for severe secondary stereotypies. Parkinsonism Relat Disord. 2014;20(9):1035–6.

    Article  PubMed  Google Scholar 

  32. Benedetti-Isaac JC, Torres-Zambrano M, Vargas-Toscano A, Perea-Castro E, Alcala-Cerra G, Furlanetti LL, et al. Seizure frequency reduction after posteromedial hypothalamus deep brain stimulation in drug-resistant epilepsy associated with intractable aggressive behavior. Epilepsia. 2015;56(7):1152–61.

    Article  CAS  PubMed  Google Scholar 

  33. Segar DJ, Chodakiewitz YG, Torabi R, Cosgrove GR. Deep brain stimulation for the obsessive-compulsive and Tourette-like symptoms of Kleefstra syndrome. Neurosurg Focus. 2015;38(6):E12.

    Article  PubMed  Google Scholar 

  34. Park HR, Kim IH, Kang H, Lee DS, Kim BN, Kim DG, et al. Nucleus accumbens deep brain stimulation for a patient with self-injurious behavior and autism spectrum disorder: functional and structural changes of the brain: report of a case and review of literature. Acta Neurochir. 2017;159(1):137–43.

    Article  PubMed  Google Scholar 

  35. Doshi PK, Hegde A, Desai A. Nucleus accumbens deep brain stimulation for obsessive-compulsive disorder and aggression in an autistic patient: a case report and hypothesis of the role of nucleus accumbens in autism and comorbid symptoms. World Neurosurg. 2019;125:387–91.

    Article  PubMed  Google Scholar 

  36. Watabe-Uchida M, Zhu L, Ogawa SK, Vamanrao A, Uchida N. Whole-brain mapping of direct inputs to midbrain dopamine neurons. Neuron. 2012;74(5):858–73.

    Article  CAS  PubMed  Google Scholar 

  37. Haber SN, Fudge JL, McFarland NR. Striatonigrostriatal pathways in primates form an ascending spiral from the shell to the dorsolateral striatum. J Neurosci. 2000;20(6):2369–82.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Langen M, Bos D, Noordermeer SD, Nederveen H, van Engeland H, Durston S. Changes in the development of striatum are involved in repetitive behavior in autism. Biol Psychiatry. 2014;76(5):405–11.

    Article  PubMed  Google Scholar 

  39. Cauda F, Geda E, Sacco K, D'Agata F, Duca S, Geminiani G, et al. Grey matter abnormality in autism spectrum disorder: an activation likelihood estimation meta-analysis study. J Neurol Neurosurg Psychiatry. 2011;82(12):1304–13.

    Article  PubMed  Google Scholar 

  40. Shen MD, Li DD, Keown CL, Lee A, Johnson RT, Angkustsiri K, et al. Functional connectivity of the amygdala is disrupted in preschool-aged children with autism spectrum disorder. J Am Acad Child Adolesc Psychiatry. 2016;55(9):817–24.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Ho AL, Salib AN, Pendharkar AV, Sussman ES, Giardino WJ, Halpern CH. The nucleus accumbens and alcoholism: a target for deep brain stimulation. Neurosurg Focus. 2018;45(2):E12.

    Article  PubMed  Google Scholar 

  42. Wilden JA, Qing KY, Hauser SR, McBride WJ, Irazoqui PP, Rodd ZA. Reduced ethanol consumption by alcohol-preferring (P) rats following pharmacological silencing and deep brain stimulation of the nucleus accumbens shell. J Neurosurg. 2014;120(4):997–1005.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Islam L, Franzini A, Messina G, Scarone S, Gambini O. Deep brain stimulation of the nucleus accumbens and bed nucleus of stria terminalis for obsessive-compulsive disorder: a case series. World Neurosurg. 2015;83(4):657–63.

    Article  PubMed  Google Scholar 

  44. Vannemreddy P, Slavin K. Nucleus accumbens as a novel target for deep brain stimulation in the treatment of addiction: a hypothesis on the neurochemical and morphological basis. Neurol India. 2019;67(5):1220–4.

    Article  PubMed  Google Scholar 

  45. De Salles AAF, Barbosa DAN, Fernandes F, Abucham J, Nazato DM, Oliveira JD, et al. An open-label clinical trial of hypothalamic deep brain stimulation for human morbid obesity: BLESS Study Protocol. Neurosurgery. 2018;83(4):800–9.

    Article  PubMed  Google Scholar 

  46. Laxton AW, Tang-Wai DF, McAndrews MP, Zumsteg D, Wennberg R, Keren R, et al. A phase I trial of deep brain stimulation of memory circuits in Alzheimer's disease. Ann Neurol. 2010;68(4):521–34.

    Article  CAS  PubMed  Google Scholar 

  47. Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, Hill CL, et al. The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Arch Gen Psychiatry. 1989;46(11):1006–11.

    Article  CAS  PubMed  Google Scholar 

  48. Goodman WK, Price LH, Rasmussen SA, Mazure C, Delgado P, Heninger GR, et al. The Yale-Brown Obsessive Compulsive Scale. II. Validity. Arch Gen Psychiatry. 1989;46(11):1012–6.

    Article  CAS  PubMed  Google Scholar 

  49. Rojahn J, Matson JL, Lott D, Esbensen AJ, Smalls Y. The Behavior Problems Inventory: an instrument for the assessment of self-injury, stereotyped behavior, and aggression/destruction in individuals with developmental disabilities. J Autism Dev Disord. 2001;31(6):577–88.

    Article  CAS  PubMed  Google Scholar 

  50. Klonsky ED, Olino TM. Identifying clinically distinct subgroups of self-injurers among young adults: a latent class analysis. J Consult Clin Psychol. 2008;76(1):22–7.

    Article  PubMed  Google Scholar 

  51. Bodfish JW, Symons FJ, Parker DE, Lewis MH. Varieties of repetitive behavior in autism: comparisons to mental retardation. J Autism Dev Disord. 2000;30(3):237–43.

    Article  CAS  PubMed  Google Scholar 

  52. Aman MG, Singh NN, Stewart AW, Field CJ. Psychometric characteristics of the aberrant behavior checklist. Am J Ment Defic. 1985;89(5):492–502.

    CAS  PubMed  Google Scholar 

  53. Aman MG, Singh NN, Stewart AW, Field CJ. The aberrant behavior checklist: a behavior rating scale for the assessment of treatment effects. Am J Ment Defic. 1985;89(5):485–91.

    CAS  PubMed  Google Scholar 

  54. Min CH, Tewfik AH. Automatic characterization and detection of behavioral patterns using linear predictive coding of accelerometer sensor data. Conf Proc IEEE Eng Med Biol Soc. 2010;2010:220–3.

    Google Scholar 

  55. Doherty A, Jackson D, Hammerla N, Plotz T, Olivier P, Granat MH, et al. Large scale population assessment of physical activity using wrist worn accelerometers: the UK Biobank Study. PLoS One. 2017;12(2):e0169649.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  56. Amiri AM, Peltier N, Goldberg C, Sun Y, Nathan A, Hiremath SV, et al. WearSense: detecting autism stereotypic behaviors through smartwatches. Healthcare (Basel). 2017;5(1):1–9.

    CAS  Google Scholar 

  57. Zhang HW, Li DY, Zhao J, Guan YH, Sun BM, Zuo CT. Metabolic imaging of deep brain stimulation in anorexia nervosa: a 18F-FDG PET/CT study. Clin Nucl Med. 2013;38(12):943–8.

    Article  PubMed  Google Scholar 

  58. Kahn L, Sutton B, Winston HR, Abosch A, Thompson JA, Davis RA. Deep brain stimulation for obsessive-compulsive disorder: real world experience post-FDA-humanitarian use device approval. Front Psych. 2021;12:568932.

    Article  Google Scholar 

  59. Roet M, Boonstra J, Sahin E, Mulders AEP, Leentjens AFG, Jahanshahi A. Deep brain stimulation for treatment-resistant depression: towards a more personalized treatment approach. J Clin Med. 2020;9(9):1–20.

    Article  Google Scholar 

  60. Sullivan CRP, Olsen S, Widge AS. Deep brain stimulation for psychiatric disorders: From focal brain targets to cognitive networks. Neuroimage. 2021;225:117515.

    Article  PubMed  Google Scholar 

  61. Bronsard G, Botbol M, Tordjman S. Aggression in low functioning children and adolescents with autistic disorder. PLoS One. 2010;5(12):e14358.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  62. Goldman S, Wang C, Salgado MW, Greene PE, Kim M, Rapin I. Motor stereotypies in children with autism and other developmental disorders. Dev Med Child Neurol. 2009;51(1):30–8.

    Article  PubMed  Google Scholar 

  63. Langen M, Durston S, Kas MJ, van Engeland H, Staal WG. The neurobiology of repetitive behavior: ...and men. Neurosci Biobehav Rev. 2011;35(3):356–65.

    Article  PubMed  Google Scholar 

  64. Davidson B, Elkaim LM, Lipsman N, Ibrahim GM. Editorial. An ethical framework for deep brain stimulation in children. Neurosurg Focus. 2018;45(3):E11.

    Article  PubMed  Google Scholar 

  65. Dowd RS, Pourfar M, Mogilner AY. Deep brain stimulation for Tourette syndrome: a single-center series. J Neurosurg. 2018;128(2):596–604.

    Article  PubMed  Google Scholar 

  66. Servello D, Porta M, Sassi M, Brambilla A, Robertson MM. Deep brain stimulation in 18 patients with severe Gilles de la Tourette syndrome refractory to treatment: the surgery and stimulation. J Neurol Neurosurg Psychiatry. 2008;79(2):136–42.

    Article  CAS  PubMed  Google Scholar 

Download references


Not applicable.


This research received funding from the Hospital for Sick Children Centre for Brain and Mental Health, the Sandra Brown Health Outcomes Grant.

Author information

Authors and Affiliations



This study was conceived by GMI, with clinical implementation by SB, CG, AF, AR and AL. The manuscript was written by HY, with significant contributions by LS, SB, AR, AL and AVK. Inclusion criteria and selection of outcome measures influenced by GMI, HY, AR, AL, and AVK. All authors read and approved the final manuscript.

Corresponding author

Correspondence to George M. Ibrahim.

Ethics declarations

Ethics approval and consent to participate

This trial was approved by the Research Ethics Board at the Hospital of Sick Children, with protocol number 1000060282. Consent to participate in the trial is acquired from parent or legal guardians and assent is sought from the child or adolescent.

Consent for publication

Not applicable.

Competing interests

A.F. is a consultant for Abbott, Ceregate, Ipsen, Medtronic, Boston Scientific, and AbbVie Inc. He has received research support from Medtronic, Boston Scientific, University of Toronto, Michael J. Fox Foundation for Parkinson’s Research, Dystonia Medical Research Foundation, and honoraria for serving as a speaker from Abbott, UCB, Medtronic, Paladin, Sunovion, Ipsen, Boston Scientific, AbbVie Inc. There are no other declarations of COI.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Yan, H., Siegel, L., Breitbart, S. et al. An open-label prospective pilot trial of nucleus accumbens deep brain stimulation for children with autism spectrum disorder and severe, refractory self-injurious behavior: study protocol. Pilot Feasibility Stud 8, 24 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: