# Catatonia in Children and Adolescents

## Introduction

Catatonia is a neuropsychiatric syndrome characterized by motor, behavioral, and affective disturbances that occurs across a wide range of psychiatric and medical conditions. Although historically associated with schizophrenia in adults, catatonia in children and adolescents is increasingly recognized as a distinct clinical entity with diverse etiologies. Prompt recognition is critical because catatonia is highly treatable yet can progress to life-threatening malignant catatonia if missed.

## Epidemiology

The prevalence of catatonia in pediatric psychiatric inpatients is estimated at 1.5-6%, though it is likely underdiagnosed. It occurs across all ages, including preschool-age children. There is an equal sex distribution in prepubertal children with a slight female predominance in adolescents. In pediatric populations, catatonia is most commonly associated with mood disorders, unlike in adults where schizophrenia predominates. Autism spectrum disorder is a particularly important risk factor in children.

## Etiology

### Psychiatric Conditions

Mood disorders, including bipolar disorder and major depressive disorder, are the most common psychiatric cause in youth. Psychotic disorders such as schizophrenia and brief psychotic disorder may also present with catatonia. An estimated 12-18% of individuals with autism spectrum disorder develop catatonia. Acute stress, trauma, and medication-related causes, particularly neuroleptic-induced catatonia, are additional psychiatric etiologies.

### Medical and Neurological Conditions

Anti-NMDA receptor encephalitis is critical to consider in any child with acute-onset catatonia, as this autoimmune condition is more common in children than previously recognized. Other autoimmune encephalitides, including anti-LGI1 and anti-CASPR2 variants, should also be considered. Infections such as encephalitis, HIV, and neurosyphilis may present with catatonia. Metabolic derangements including hepatic encephalopathy and Wilson disease are potential causes. Seizure disorders and medication effects, particularly neuroleptic malignant syndrome and abrupt discontinuation of benzodiazepines or dopamine agonists, complete the differential.

## Clinical Features

### DSM-5 Criteria

The diagnosis requires at least three of twelve specified features: stupor, which involves no psychomotor activity and no relating to the environment; catalepsy, the passive induction and maintenance of postures against gravity; waxy flexibility, a slight, even resistance to positioning; mutism; negativism, or opposition to instructions or external stimuli; posturing, the spontaneous maintenance of postures against gravity; mannerisms; stereotypies; agitation not influenced by external stimuli; grimacing; echolalia; and echopraxia.

### Pediatric-Specific Considerations

In young children, catatonia may present primarily as regression in motor and language skills. Withdrawal, food refusal, and incontinence are common presenting features. Children with ASD may show worsening of stereotypies, mutism, and immobility. Excited catatonia may be misdiagnosed as agitation or mania.

## Assessment

### Clinical Rating Scale

The Bush-Francis Catatonia Rating Scale is the most widely used assessment tool. Originally validated in adults, it has been adapted for pediatric use. This 23-item scale covers motor and behavioral signs, and serial measurement helps track treatment response.

### Diagnostic Workup

The lorazepam challenge test involves administering 1-2 mg of intravenous lorazepam; marked improvement within minutes strongly supports the diagnosis of catatonia. Laboratory evaluation should include a complete metabolic panel, thyroid function tests, and ammonia level. Anti-NMDA receptor antibodies should be tested in both serum and cerebrospinal fluid. An autoimmune encephalitis panel, brain MRI, and EEG to rule out non-convulsive status epilepticus are indicated. Inflammatory markers including CRP, ESR, and ANA should be obtained. Creatine kinase is elevated in malignant catatonia. A urine drug screen completes the workup.

## Treatment

### First-Line: Benzodiazepines

Lorazepam is the treatment of choice. The starting dose is 0.5-1 mg orally or intravenously two to three times daily, titrated to response. Doses up to 8-16 mg per day may be needed. The response rate in pediatric catatonia is 60-80%, and response may be dramatic and rapid, occurring within hours to days. The medication should be tapered slowly once catatonia has resolved, as premature discontinuation risks relapse.

### Second-Line: Electroconvulsive Therapy (ECT)

ECT is indicated when benzodiazepines fail or when catatonia is malignant. It is highly effective, with response rates exceeding 80-90% even in treatment-resistant cases. Bilateral electrode placement with typically 6-12 sessions is standard. ECT is safe in children and adolescents, with cognitive side effects that are generally mild and transient. Legal barriers to ECT in minors vary by jurisdiction and can delay treatment.

| Treatment | Indication | Dosing/Protocol | Response Rate | Key Considerations |
|---|---|---|---|---|
| Lorazepam | First-line for all catatonia | 0.5-1 mg PO/IV 2-3x daily; titrate to 8-16 mg/day | 60-80% | Dramatic, rapid response possible; taper slowly to prevent relapse |
| ECT | Benzodiazepine failure or malignant catatonia | Bilateral, 6-12 sessions | 80-90% | Safe in youth; legal barriers vary by jurisdiction |
| Immunotherapy | Anti-NMDA receptor encephalitis | IVIG, plasmapheresis, corticosteroids, rituximab | Varies by etiology | Always test for anti-NMDA antibodies in new-onset catatonia |

### Treatment of Underlying Cause

Anti-NMDA receptor encephalitis requires immunotherapy, including IVIG, plasmapheresis, corticosteroids, and rituximab. Infections, metabolic derangements, and other medical causes should be treated directly. Neuroleptics must be stopped if neuroleptic malignant syndrome or neuroleptic-induced catatonia is suspected.

### Malignant Catatonia

Malignant catatonia is a medical emergency characterized by fever, autonomic instability, rigidity, altered consciousness, and elevated creatine kinase. It overlaps clinically with neuroleptic malignant syndrome. Management requires ICU-level care, intravenous lorazepam, and urgent ECT if the patient is unresponsive to benzodiazepines. Mortality is significant without treatment.

## Clinical Pearls

Catatonia should be considered in any child with acute-onset mutism, immobility, or regression, as it is treatable and should not be missed. Anti-NMDA receptor encephalitis must be ruled out in every case of new-onset catatonia in youth. The lorazepam challenge is both diagnostic and therapeutic, and a positive response strongly supports the diagnosis. Antipsychotics can worsen catatonia and precipitate malignant catatonia, so neuroleptics should be withheld until catatonia is resolved.

## References

1. Dhossche DM, et al. "Catatonia in Autism Spectrum Disorders." *Journal of Autism and Developmental Disorders*. 2006;36(2):225-232.
2. Consoli A, et al. "Recognition of Catatonia in Children and Adolescents." *Journal of Clinical Psychiatry*. 2012;73(6):e777.
3. DeJong H, et al. "Pediatric Catatonia: A Systematic Review and Meta-Analysis." *European Child and Adolescent Psychiatry*. 2021;30(9):1353-1368.
4. Fink M, Taylor MA. *Catatonia: A Clinician's Guide to Diagnosis and Treatment.* Cambridge: Cambridge University Press; 2003.