Ryan S. Sultan, MD

Catatonia in Children and Adolescents

Pediatric Neuropsychiatry Case Conference

Introduction: The Hidden Diagnosis in Pediatric Psychiatry

Catatonia is a neuropsychiatric syndrome characterized by motor, behavioral, and affective abnormalities. Despite being relatively common in pediatric psychiatric populations (estimated 10-20% of acutely ill psychiatric inpatients), it remains underrecognized and undertreated in children and adolescents.

Case Presentation: "Roza"

Chief Complaint & Presentation

Roza, an adolescent with a complex psychiatric history, presented to the hospital with altered mental status (AMS), posturing, and psychomotor abnormalities. She had a history of multiple psychiatric admissions and trials of various psychotropic medications, including antipsychotics.

Psychiatric Timeline

Baseline Functioning: Prior psychiatric history with mood symptoms, psychotic features, and behavioral dysregulation. Multiple medication trials including aripiprazole (Abilify) and others.

Recent Course:

• Early 2012: Discontinued Abilify
• Neurology gave trial of Prozac → Possible manic episode
• Progressive decline in functioning
• Development of motor abnormalities and behavioral regression

Neurological History & Examination

Key Neurological Findings:

• Posturing - Abnormal, fixed positioning of limbs
• Catalepsy - Waxy flexibility, limb positioning maintained
• Mutism or reduced speech
• Staring - Reduced eye contact, fixed gaze
• Grimacing
• Stereotypies - Repetitive, purposeless movements
• Negativism - Opposition to instructions

Videos of Patient (3/10/15)

[Note: Clinical videos were presented during conference showing patient's motor abnormalities, posturing, mutism, and response to benzodiazepine challenge]

Differential Diagnosis of Altered Mental Status with Motor Abnormalities

Busch-Francis Catatonia Rating Scale (BFCRS)

The Busch-Francis Catatonia Rating Scale is the gold-standard assessment tool for diagnosing and quantifying catatonia severity. A score of 2 or more indicates clinically significant catatonia.

The 23 Items of the Busch-Francis Scale:

Scoring: 0 = Absent, 1 = Mild, 2 = Moderate, 3 = Severe

Roza's Busch-Francis Score

Based on clinical presentation, Roza demonstrated multiple catatonic features including:

• Posturing (score: 2-3)
• Mutism (score: 2-3)
• Staring (score: 2)
• Grimacing (score: 2)
• Stereotypies (score: 2)
• Negativism (score: 2)
• Rigidity (score: 2)

Total BFCRS Score: >14 - indicating severe catatonia

Catatonia in Children and Autism Spectrum Disorder

Catatonia has a special relationship with autism spectrum disorder (ASD). Wing & Shah (2000) described catatonia-like features in individuals with ASD:

Catatonic Features in ASD:

• Increased passivity and lack of motivation
• Reversal of circadian rhythms - Sleep-wake cycle disruption
• Parkinsonian features - Slowness, rigidity, reduced facial expression
• Excitement and agitation - Sudden behavioral escalation
• Increased repetitive and ritualistic behavior - Beyond baseline autism symptoms

Clinical Consideration: Individuals with intellectual disability (ID) or autism may have high incidence of extrapyramidal symptoms (EPS) with antipsychotics. Is the rigidity from medication, catatonia, or both?

Medical Consequences of Catatonia

Serious Medical Complications:

Mortality Rate: Historically, untreated malignant catatonia had mortality rates of 10-20%. With modern treatment (benzodiazepines, ECT), mortality has decreased significantly but remains a medical emergency.

Treatment of Catatonia in Children and Adolescents

1. Benzodiazepine Challenge/Treatment

Lorazepam (Ativan) is the gold-standard first-line treatment for catatonia.

Benzodiazepine Challenge Test:

• Give 1-2 mg lorazepam IV or IM
• Assess for improvement in catatonic symptoms within 10-15 minutes
• Positive response confirms catatonia diagnosis
• 70-80% of catatonia patients respond to lorazepam

Ongoing Treatment Protocol:

• Start lorazepam 1-2 mg PO/IV TID
• Can increase up to 24 mg/day (in divided doses)
• Continue until catatonic symptoms resolve
• Taper gradually after stabilization (weeks to months)

2. Electroconvulsive Therapy (ECT)

ECT is the most effective treatment for catatonia, with response rates of 80-100%.

Indications for ECT in Pediatric Catatonia:

• Lorazepam non-response - Failed adequate trial (>24 mg/day × 3-5 days)
• Malignant catatonia - Autonomic instability, hyperthermia, life-threatening
• Severe malnutrition/dehydration - Cannot wait for slower medication response
• Life-threatening complications - PE, severe rhabdomyolysis

ECT Protocol for Catatonia:

• Bilateral electrode placement (more effective for catatonia than unilateral)
• 3 sessions per week
• Usually requires 6-12 treatments
• Often see dramatic improvement after 1-3 treatments
• ECT is safe in adolescents and even younger children when indicated

3. Role of Antipsychotics

Controversy: Should antipsychotics be used in catatonia?

Arguments AGAINST antipsychotics in catatonia:

• Risk of worsening catatonia
• Risk of neuroleptic malignant syndrome (NMS)
• Many cases of catatonia triggered or worsened by antipsychotics

When antipsychotics MAY be considered:

• After catatonia resolved with benzodiazepines/ECT
• If underlying psychotic disorder requires treatment
• Clozapine - Appears safest antipsychotic in catatonia (least EPS risk)
• Use cautiously, at low doses, with close monitoring

4. Treatment of Motor Symptoms

If parkinsonian symptoms or rigidity present:

• Benztropine (Cogentin) - Anticholinergic for EPS
• However, distinguish true EPS from catatonia features
• Lorazepam/ECT will improve catatonic rigidity

Discussion Points from Case Conference

1. Is Roza's Presentation More Thought Disorder Than Mood Disorder?

Catatonia can occur in context of:

• Schizophrenia spectrum disorders - Especially with prominent thought disorder
• Mood disorders - Major depression (most common), bipolar disorder
• Autism spectrum - Particularly in adolescence
• Medical conditions - Encephalitis, metabolic, autoimmune

Roza's baseline included both psychotic features and mood symptoms. The presence of catatonia doesn't definitively answer the underlying diagnosis—it's a syndrome that can occur across multiple conditions.

2. Treatment Considerations for Roza

Options under discussion:

• Continue/optimize lorazepam - Increase dose if partial response
• Consider ECT - If lorazepam non-response or life-threatening complications
• Higher dose antipsychotic? - RISKY - could worsen catatonia
• Clozapine? - Safest antipsychotic option if psychosis requires treatment
• Begin treatment of motor symptoms with Cogentin? - May help if EPS component

Conference Consensus: Optimize lorazepam first. If inadequate response, strongly consider ECT given severity and medical risks.

3. What Does the Family Need?

• Education about catatonia - What it is, why it happened, prognosis
• Understanding of treatment plan - Benzodiazepines, possible ECT
• Long-term planning - Preventing recurrence, monitoring for prodromal signs
• Psychosocial support - Catatonia is frightening for families
• Coordination with schools/services - Extended absence, functional recovery

4. Thoughts on Current Motor Symptoms

Differential of motor symptoms:

• Catatonia (primary)
• Antipsychotic-induced EPS (iatrogenic)
• Part of autism spectrum baseline (developmental)
• Combination of above

Individuals with intellectual disability/autism have higher incidence of EPS with antipsychotics. The motor symptoms could represent:

1. Pure catatonia (will respond to lorazepam/ECT)
2. Catatonia + antipsychotic EPS (needs both treatment and medication adjustment)
3. Autism baseline + catatonia overlay

Key Takeaways for Clinicians

References

1. Wing L, Shah A. (2000). Catatonia in autistic spectrum disorders. British Journal of Psychiatry, 176, 357-362.
2. Clinebell K, et al. (2014). Guidelines for preventing medical complications of catatonia: case report and literature review. Journal of Clinical Psychiatry, 75(6), 644-651.
3. Daniels J. (2009). Catatonia: Clinical aspects and neurobiological correlates. Journal of Neuropsychiatry and Clinical Neurosciences, 21(4), 371-380.
4. Leonhard K. (1999). Early childhood catatonia. In: Leonhard K, Beckmann H (editor), Cahn CH (translator). Classification of endogenous psychoses and their differentiated etiology. 2nd ed., Vienna: Springer-Verlag, 330-383.
5. Dhossche D, Wachtel L. (2010). Catatonia is hidden in plain sight among different pediatric disorders: A review article. Pediatric Neurology, 43(5), 307-315.
6. Bush G, Fink M, Petrides G, Dowling F, Francis A. (1996). Catatonia. I. Rating scale and standardized examination. Acta Psychiatrica Scandinavica, 93(2), 129-136.

Related Resources

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• Tantrums & Emotional Dysregulation - Differential diagnosis in children
• Off-Label Antipsychotic Prescribing - Medication safety considerations
• Antipsychotics in ADHD - Adverse effects and monitoring

Pediatric Psychiatry Resources:

• ADHD in Children - Ages 6-12 evaluation and treatment
• ADHD in Adolescents - Teenage presentations
• ADHD Diagnosis - Comprehensive assessment
• ADHD Medications - Treatment options

Research & Education:

• Research Publications - Peer-reviewed work
• Conference Presentations - Academic talks
• Clinical Articles - Educational content
• Teaching & Education - Medical education
• Academic CV - Professional background