ABSTRACT

Objective

Transcranial magnetic stimulation (TMS) is a non-invasive modulation technique. While TMS is used in many fields among adult patients, its use in child and adolescent mental health is limited. This study aims to evaluate levels of knowledge, clinical experiences, and attitudes of child and adolescent psychiatrists regarding TMS and to identify potential barriers and facilitators to the application of TMS.

Methods

The study included 115 child and adolescent psychiatrists actively working in various institutions across Türkiye. Data were collected via a structured online questionnaire that inquired about participants’ demographic characteristics and their knowledge levels, experiences, perceptions of efficacy and safety, and training regarding TMS protocols.

Results

While 68.7% of participants reported having a “low” general knowledge about TMS, 96.5% had received no formal training in this area. Although the indication for major depressive disorder was known to 93.9% of participants, only 8.7% of physicians had experience with TMS in the pediatric patient group. The biggest barriers to clinical practice were reported to be problems accessing equipment and a lack of information or training. The successful clinical case studies and increased training opportunities emerged as the most important facilitating factors.

CONCLUSION

Although professionals in child and adolescent psychiatry have a positive view of TMS therapy and show strong interest in learning about it, there are deficiencies in training and experience. To ensure the safe and evidence-based use of TMS, it is implement structured TMS training and to increase its accessibility in hospitals.

INTRODUCTION

Transcranial magnetic stimulation (TMS) is a non-invasive treatment method that induces an electric current in the brain through a magnetic field. TMS aims to induce changes in intracranial actvity through neuronal pathways and neurotransmitter release (1, 2). Physiological mechanism of TMS includes neuroplasticity creating long-lasting effects in the brain (3). TMS was first approved by the US Food and Drug Administration (FDA) in 2008 for the treatment of refractory depression in adults. Since then, with the help of developing technological advances, it has become a treatment method applicable to a variety of conditions (4). Currently, various studies are being conducted regarding the use of TMS in many psychiatric and neurological disorders such as major depressive disorder (MDD), obsessive-compulsive disorder (OCD), anxiety disorders, stroke, substance abuse, and schizophrenia (5, 6), but its effectiveness in treatment-resistant depression is most consistent (6-8). TMS in anxiety disorders was also suggested to be a viable and safe method (9). Furthermore, the role of TMS treatment in post-stroke rehabilitation and substance use disorders is also being investigated (10, 11). Although TMS in adult psychiatry have an extended clinical use, its use in child and adolescent patients is approached cautiously due to the complexity of the developing brain and its safety profile (12, 13).

Until recently, TMS had been used experimentally in child and adolescent mental health, including MDD, ASD, and attention deficit hyperactivity disorder (ADHD) (14, 15). In 2024, TMS was approved by the FDA for the treatment of depression in adolescents (16). This approval is expected to pave the way for greater use of TMS in clinical practice.

Although experimental studies have been conducted and the recent approval for use in adolescents has been confirmed, child and adolescent psychiatrists may have variable attitudes toward the use of TMS in adolescents. T hat it is not available in every clinic may raise questions regarding TMS. Several studies are currently being conducted to investigate clinicians’ perspectives on the use of TMS. A study showed that while 71% of clinicians believed they would refer patients for TMS treatment in the future, 67% were lack of knowledge on TMS referral (17). Another study indicated that 80% of clinicians had sufficient knowledge about TMS, but only 53% said they would accept TMS treatment if they were patients themselves (18). A study about perceptions of psychiatrists in China found that many clinicians had insufficient knowledge of TMS (19). A recent study conducted in Europe found that clinical experience with TMS was limited, and most participants expressed a desire for increased clinical training on TMS (20). A study in 2024 found that knowledge of TMS was higher among those working in academic centers (21); another study conducted in Türkiye emphasized that while most psychiatrists viewed TMS as a positive treatment method, more training and clinical experience were needed (22). Studies show that as training and clinical experience increase, so does the positive attitude towards TMS (17).

Although numerous studies have examined adult psychiatrists’ knowledge, attitudes, competencies, and expectations regarding TMS, research in child and adolescent mental health remains limited. The growing body of evidence regarding TMS, coupled with its approval for use in adolescent depression, is leading to increased interest in TMS and its adoption in clinical practice. The gaps in current literature highlight the need to conduct further research on TMS and to clarify clinicians’ needs, experiences, perspectives, and expectations toward TMS. Our study aimed to assess the knowledge, attitudes, and clinical experiences of child and adolescent psychiatrists regarding TMS treatment. The primary objectives of the study are to identify clinical training needs and provide data that will facilitate the integration of TMS into clinical practice in child and adolescent psychiatry.

MATERIALS AND METHODS

Methods

Study Design

A descriptive, cross-sectional survey methodology was utilized to examine TMS-related knowledge, perceived barriers, and potential facilitators of clinical implementation among child and adolescent psychiatry professionals in Türkiye. The study was non-interventional in nature and was conducted entirely through an online, self-administered questionnaire format. Ethical approval was granted by the Gazi University Rectorate Ethics Committee (approval number: 2024-1813, meeting date: 26.11.2024, meeting no: 19), and all participants provided electronic informed consent before completing the survey.

Participants

The study targeted professionals in child and adolescent psychiatry who were actively engaged in clinical practice in Türkiye during the data collection period. Inclusion criteria encompassed three groups: board-certified child and adolescent psychiatrists, psychiatry residents undergoing specialty training in child and adolescent psychiatry, and academics in child and adolescent psychiatry. Participants were not excluded based on age, gender, years of clinical experience, or institutional affiliation; institutional affiliations included university hospitals, training and research hospitals, state hospitals, and private practice settings. Participation was entirely voluntary; no identifying information was collected, and no form of compensation was offered.

Survey Administration

Data were collected via an electronic questionnaire developed and distributed through Google Forms. The survey link was disseminated through professional email distribution lists and a closed WhatsApp group consisting of child and adolescent psychiatry specialists, residents, and academic faculty from across Türkiye. All responses were collected without personal identifiers to ensure anonymity, and data were stored in a password-protected institutional database with access restricted to the research team.

Survey Content

The survey consisted of basic demographic items followed by 15 questions assessing child and adolescent psychiatry professionals’ knowledge, attitudes, and experiences regarding TMS. The questionnaire was partially adapted from existing literature investigating mental health professionals’ attitudes toward diverse treatment modalities (18, 23, 24).

Demographic variables included age, sex, years of clinical experience in mental health, and geographic location of practice. Knowledge-based items evaluated participants’ familiarity with TMS protocols, indications, and underlying mechanisms. Perception-oriented questions assessed professional attitudes regarding the efficacy and safety of TMS in adolescents. Finally, experience-related items focused on the participants’ previous clinical use of TMS and formal training history.

Statistical Analysis

All statistical analyses were carried out using IBM SPSS Statistics, Version 26.0. For continuous variables, descriptive statistics were reported as means, standard deviations, medians, and ranges, whereas categorical variables were summarized using frequencies and percentages. The normality assumption was evaluated through skewness and kurtosis indices. Comparisons between groups for categorical variables were conducted using chi-square tests; Fisher’s exact test was applied when cell frequencies were insufficient to meet the assumptions of the chi-square test. A p-value of less than 0.05 was considered statistically significant throughout all analyses.

 Although year of experience were initially recorded across four categories (≤5, 6–10, 11–20, and ≥21 years), the small cell sizes in the upper categories precluded their use as independent groups in inferential analyses. For chi-square comparisons, experience was dichotomized into two groups: five or fewer years (n = 57) and more than five years (n = 58).

RESULTS

A total of 115 child and adolescent psychiatry professionals participated in the study. The majority of participants were between the ages of 30 and 39 years (59.1%), while 35.7% were under 30 years of age and 5.2% were 40 years or older. Female participants constituted 76.5% of the sample (n = 88). In terms of professional experience, 49.6% of participants had 5 or fewer years, 44.3% had 6 to 10 years, and 6.1% had 11 or more years. Geographically, the largest proportion of respondents worked in the Central Anatolia Region (40.9%), followed by the Marmara Region (21.7%) and the Aegean Region (12.2%). Baseline demographic and professional characteristics of the sample are presented in Table 1.

The knowledge levels and the comparisons between the experience groups are summarized in Table 2. The overall level of knowledge regarding TMS was low across both experience groups. Among participants with 5 or fewer years of experience, 38 (66.7%) reported limited knowledge of TMS, 12 (21.1%) reported moderate knowledge, and only 1 participant reported high knowledge. A similar distribution was observed among participants with more than 5 years of experience, with 41 (70.7%) reporting limited knowledge. No statistically significant difference was found between the two groups with respect to overall TMS knowledge level (p = 0.871). Over half of participants (56.5%) reported no knowledge of TMS protocols, while only 3.5% described their knowledge as high. This distribution also did not differ significantly between the two experience groups (p = 0.954). Regarding knowledge of clinical indications, the majority of participants (93.9%) correctly identified MDD as an indication for TMS. Recognition of MDD was higher among participants with less experience (98.2% vs. 89.7%). A trend toward significance was observed (p = 0.054). In contrast, recognition of alcohol and substance use disorders as an indication for TMS was more prevalent in the more experienced group (24.1% vs. 10.5%), and a trend toward significance was observed for this comparison (p = 0.054). Knowledge of OCD as an indication was significantly more common among participants with more experience than among those with less experience (p = 0.032). No significant between-group differences were observed for anxiety disorders, autism spectrum disorder (ASD), ADHD, or alcohol and substance use disorders. Only a small proportion of participants reported prior experience with TMS in a pediatric population (8.7%), and formal training in TMS was rare in both groups (3.5%).

Perceptions regarding the clinical effectiveness of TMS for MDD in children and adolescents were mixed. The most common response was “moderately effective” (42.6%), while 29.6% of participants indicated they were unsure of TMS’s effectiveness. Only 5.2% considered TMS to be highly effective in this population. No statistically significant difference was found between the two experience groups (p = 0.822). With respect to safety, the majority of participants rated TMS as moderately safe (42.6%) or very safe (25.2%) for use in children and adolescents, while 27.0% were unsure. Group differences in safety perceptions were not statistically significant (p = 0.640). Regarding the role of TMS in treatment algorithms, most participants (60.0%) disagreed that TMS should be considered a first-line treatment option for MDD in children and adolescents, while 36.5% neither agreed nor disagreed. Only 3.5% expressed agreement. This distribution did not differ significantly between the two groups (p = 0.408). When asked about the perceived benefits of TMS as an adjunctive treatment for pediatric psychiatric disorders, 49.6% of participants described it as moderately beneficial and 17.4% as highly beneficial. Approximately one-fifth of participants (20.9%) were unsure, whereas only 0.9% considered TMS not beneficial. No significant group differences were identified (p = 0.104; Table 3).

The perceived barriers to, and potential facilitators of, clinical use of TMS, according to participants, are shown in Table 4. Among the identified barriers to gaining experience with TMS, limited accessibility was the most frequently cited concern (75.5%), followed by lack of knowledge and/or education (46.1%), insufficient evidence for efficacy (16.7%), and safety concerns (6.9%). Regarding potential facilitators, the availability of clinical case studies demonstrating successful use was ranked highest (73.9%), followed by greater accessibility of TMS services (61.7%), more education and training opportunities (59.1%), collegial support or consultation (58.3%), and greater accessibility of clinical guidelines (48.7%).

DISCUSSION

This study is one of the pioneering studies evaluating the knowledge, attitudes, and clinical experience of child and adolescent psychiatrists regarding the application of TMS in adolescents. The findings are generally consistent with those reported in other studies. In our study, 68.7% of the professionals had “little knowledge” about TMS, and 96.5% had not received any training on this subject. This data was found to be consistent with studies conducted with adult psychiatrists in the literature (19). Our results were also in line with a study conducted on adult psychiatrists in Türkiye, which highlighted “insufficient clinical experience despite positive attitudes”(22). A similar barrier to practice appears to exist in the field of child and adolescent psychiatry. In our study, 82.6% of professionals expressed a desire to receive training on TMS, which indicates the global training need and gap (20, 25).

A large proportion of professionals participating in our study (93.9%) were aware of TMS as a treatment for MDD. This high rate can be explained by the fact that TMS has been approved by the FDA since 2008 (26). Participants with more experience were more aware of the use of TMS to treat OCD than participants with <5 years of experience. This might be due to not having an FDA clearence for TMS use in adolescents with OCD altough it is approved for adults and has growing evidence on adolescents (27) leading a high percent of knowledge (72.2%) in total for OCD. In addition, some of the participants agreed that TMS is related to neurodevelopmental disorders, including ASD and ADHD. The recent increase in experimental studies on the use of TMS in neurodevelopmental disorders may have improved the awareness of professionals in this area (28). One of the most striking results of our study is that 91.3% of the professionals have never used TMS. Although the FDA’s approval of TMS for the treatment of MDD in adolescents in March 2024 (16) is an important development, our findings indicate that this approval has not yet been fully reflected in clinical practice. A study demonstrating a lack of familiarity with the referral process of physicians (17) aligns with the findings in our study, where physicians viewed “lack of knowledge and training” as the primary obstacle to practice. This demonstrates the need for infrastructure and training support for the method to be implemented in clinical practice. Another study found that TMS knowledge was higher among those working in academic centers (21). This also supports increasing TMS units in training and research hospitals in Türkiye and incorporating structured training into the curriculum.

Although the literature highlights that TMS is a non-invasive and safe method that is well-tolerated in the pediatric age group (5, 29, 30) the fact that 42.6% of the participants were hesitant about safety indicates a need for more clinical practice in child and adolescent mental health clinics. This situation can also be attributed to the fact that the neuroplasticity capacity and developmental complexity of the child and adolescent brain necessitate a cautious approach to the use of TMS (12). To improve clinical comfort, 73.9% of the respondents requested “access to successful case studies”, suggesting that these concerns can only be reduced by presenting practical experiences. This result also supports the principle that attitudes become more positive as education and clinical experience increase (17).

Our study is of significant clinical importance, as it is, to our knowledge, the first study to evaluate child and adolescent psychiatrists’ perspectives and clinical approaches regarding TMS treatment. Notably, this study was conducted immediately following the FDA’s March 2024 approval to treat adolescent depression, providing a timely dataset that reflects the impact of global regulatory developments on clinical practice in Türkiye. Additionally, the inclusion of participants from various regions of the country and of physicians with varying levels of experience enhances the reliability and generalizability of the results.

Study Limitations

Some limitations must be considered when evaluating the findings of our study. First, the study’s sample size may not accurately reflect the approaches of the majority of the child and adolescent psychiatrists. Second, the majority of participants had never used TMS, which suggests that responses regarding safety and efficacy may have been based on theoretical knowledge or observations rather than clinical experience. Finally, measuring physicians’ interest levels by questionnaire rather than by an objective method may have introduced self-report bias.

CONCLUSION

To address the knowledge and practice gaps identified in this study, several steps are suggested. Given that 96.5% of physicians have not received specific training and 82.6% are willing to receive it, courses and modules related to TMS applications in child and adolescent mental health should be routinely incorporated into specialist training curricula. The biggest obstacle to TMS application is seen as “limited accessibility” (75.5%). Overcoming this problem could increase the use of TMS units in university and training and research hospitals. Most participants reported that awareness of successful case studies would increase their comfort with clinical use. In this context, increasing the number of clinical practice guidelines and fostering research that compiles clinical studies on the use of TMS in children and adolescents will reduce professionals’ concerns and encourage evidence-based use. Furthermore, future studies should be designed to include not only the approaches of physicians but also the clinical outcomes of treated child and adolescent patients, as well as the adherence processes and perspectives of families regarding treatment, in order to fill the gap in the literature.

Child and adolescent psychiatrists have a substantial interest in TMS, but they have difficulty translating this interest into clinical practice because of limited education, knowledge, experience, and equipment. To remove obstacles in practice, it is recommended to create structured training programs, to increase access to equipment in hospitals, and to prepare case guides. Structural support and comprehensive training are needed for the safe and widespread use of this non-invasive method in the pediatric population.