There are smaller than ITX now, but in a traditional sense it is the smallest you can go. You lose a LOT of expandability, generally limit yourself to 2X RAM sticks, and in my own experience in spite of claims about power delivery I have yet to have an ITX board that offered the overhead of ATX for power.
M-ATX is the most affordable option in mobo and case, offers expandability, and also comes pretty standard with 4X RAM. Given the pricing and the very small increase in size with the correct case it is really a great build size option IMO.