Background: Non-invasive brain stimulation is being increasingly used to interrogate neurophysiology and modulate brain function. Despite the high scientific and therapeutic potential of non-invasive brain stimulation, experience in the developing brain has been limited. Objective: To determine the safety and tolerability of non-invasive neurostimulation in children across diverse modalities of stimulation and pediatric populations. Methods: A non-invasive brain stimulation program was established in 2008 at our pediatric, academic institution. Multi-disciplinary neurophysiological studies included single-and paired-pulse Transcranial Magnetic Stimulation (TMS) methods. Motor mapping employed robotic TMS. Interventional trials included repetitive TMS (rTMS) and transcranial direct current stimulation (tDCS). Standardized safety and tolerability measures were completed prospectively by all participants. Results: Over 10 years, 384 children underwent brain stimulation (median 13 years, range 0.8e18.0). Populations included typical development (n ¼ 118), perinatal stroke/cerebral palsy (n ¼ 101), mild traumatic brain injury (n ¼ 121) neuropsychiatric disorders (n ¼ 37), and other (n ¼ 7). No serious adverse events occurred. Drop-outs were rare (<1%). No seizures were reported despite >100 participants having brain injuries and/or epilepsy. Tolerability between single and paired-pulse TMS (542340 stimulations) and rTMS (3.0 million stimulations) was comparable and favourable. TMS-related headache was more common in perinatal stroke (40%) than healthy participants (13%) but was mild and self-limiting. Tolerability improved over time with side-effect frequency decreasing by >50%. Robotic TMS motor mapping was well-tolerated though neck pain was more common than with manual TMS (33% vs 3%). Across 612 tDCS sessions including 92 children, tolerability was favourable with mild itching/tingling reported in 37%. Conclusions: Standard non-invasive brain stimulation paradigms are safe and well-tolerated in children and should be considered minimal risk. Advancement of applications in the developing brain are warranted. A new and improved pediatric NIBS safety and tolerability form is included.

Background: The options for severely disabled children with intact cognition to interact with their environment are extremely limited. A brain computer interface (BCI) has the potential to allow such persons to gain meaningful function, communication, and independence. While the pediatric population might benefit most from BCI technology, research to date has been predominantly in adults.Methods: In this prospective, cross-over study, we quantified the ability of healthy school-aged children to perform simple tasks using a basic, commercially available, EEG-based BCI. Typically developing children aged 6–18 years were recruited from the community. BCI training consisted of a brief set-up and EEG recording while performing specific tasks using an inexpensive, commercially available BCI system (EMOTIV EPOC). Two tasks were trained (driving a remote-control car and moving a computer cursor) each using two strategies (sensorimotor and visual imagery). Primary outcome was the kappa coefficient between requested and achieved performance. Effects of task, strategy, age, and learning were also explored.Results: Twenty-six of thirty children completed the study (mean age 13.2 ± 3.6 years, 27% female). Tolerability was excellent with >90% reporting the experience as neutral or pleasant. Older children achieved performance comparable to adult studies, but younger age was associated with lesser though still good performance. The car task demonstrated higher performance compared to the cursor task (p = 0.027). Thought strategy was also associated with performance with visual imagery strategies outperforming sensorimotor approaches (p = 0.031).Conclusion: Children can quickly achieve control and execute multiple tasks using simple EEG-based BCI systems. Performance depends on strategy, task and age. Such success in the developing brain mandates exploration of such practical systems in severely disabled children.

BackgroundChanges in medical education may limit opportunities for trainees to gain proficiency in surgical skills. Transcranial direct‐current stimulation (tDCS) can augment motor skill learning and may enhance surgical procedural skill acquisition. The aim of this study was to determine the effects of tDCS on simulation‐based laparoscopic surgical skill acquisition.MethodsIn this double‐blind, sham‐controlled randomized trial, participants were randomized to receive 20 min of anodal tDCS or sham stimulation over the dominant primary motor cortex, concurrent with Fundamentals of Laparoscopic Surgery simulation‐based training. Primary outcomes of laparoscopic pattern‐cutting and peg transfer tasks were scored at baseline, during repeated performance over 1 h, and again at 6 weeks. Intent‐to‐treat analysis examined the effects of treatment group on skill acquisition and retention.ResultsOf 40 participants, those receiving tDCS achieved higher mean(s.d.) final pattern‐cutting scores than participants in the sham group (207·6(30·0) versus 186·0(32·7) respectively; P = 0·022). Scores were unchanged at 6 weeks. Effects on peg transfer scores were not significantly different (210·2(23·5) in the tDCS group versus 201·7(18·1) in the sham group; P = 0·111); the proportion achieving predetermined proficiency levels was higher for tDCS than for sham stimulation. Procedures were well tolerated with no serious adverse events and no decreases in motor measures.ConclusionThe addition of tDCS to laparoscopic surgical training may enhance skill acquisition. Trials of additional skills and translation to non‐simulated performance are required to determine the potential value in medical education and impact on patient outcomes. Registration number: NCT02756052 (https://clinicaltrials.gov/).

Background: Individuals with severe neurological disabilities but preserved cognition, including children, are often precluded from connecting with their environments. Brain computer interfaces (BCI) are a potential solution where advancing technologies create new clinical opportunities. We evaluated clinician awareness as a modifiable barrier to progress and identified eligible populations. Methods: We executed a national, population-based, cross-sectional survey of physician specialists caring for persons with severe disability. An evidence-and experience-based survey had three themes: clinician BCI knowledge, eligible populations, and potential impact. A BCI knowledge index was created and scored. Canadian adult and pediatric neurologists, physiatrists and a subset of developmental pediatricians were contacted. Secure, web-based software administered the survey via email with online data collection. Results: Of 922 valid emails (664 neurologists, 253 physiatrists), 137 (15%) responded. One third estimated that ≥10% of their patients had severe neurological disability with cognitive capacity. BCI knowledge scores were low with > 40% identifying as less than "vaguely aware" and only 15% as "somewhat familiar" or better. Knowledge did not differ across specialties. Only 6 physicians (4%) had patients using BCI. Communication and wheelchair control rated highest for potentially improving quality of life. Most (81%) felt BCI had high potential to improve quality of life. Estimates suggested that > 13,000 Canadians (36 M population) might benefit from BCI technologies. Conclusions: Despite high potential and thousands of patients who might benefit, BCI awareness among clinicians caring for disabled persons is poor. Further, functional priorities for BCI applications may differ between medical professionals and potential BCI users, perhaps reflecting that clinicians possess a less accurate understanding of the desires and needs of potential end-users. Improving knowledge and engaging both clinicians and patients could facilitate BCI program development to improve patient outcomes.