What is the treatment approach for catatonia in children?

Treatment of Catatonia in Children and Adolescents

Benzodiazepines are the first-line treatment for catatonia in children, with lorazepam being the preferred agent; if benzodiazepines fail or in life-threatening situations, electroconvulsive therapy (ECT) should be initiated promptly. 1, 2

Initial Assessment and Recognition

Before initiating treatment, confirm the diagnosis of catatonia by identifying key clinical features:

• Motor symptoms: Immobility, posturing, waxy flexibility, catalepsy, stupor 3
• Behavioral manifestations: Mutism, negativism, withdrawal, psychomotor regression (particularly important in pediatric populations) 3
• Life-threatening presentations: Refusal to eat or drink, severe malnutrition, extreme suicidality, florid psychosis 1, 2
• Autonomic instability: Fever, tachycardia, blood pressure changes (suggesting malignant catatonia) 1

Critical consideration: Over 20% of pediatric catatonia cases have underlying medical conditions, making it essential to rule out organic etiologies including autoimmune encephalitis (anti-NMDA receptor), neuroleptic malignant syndrome, metabolic disorders, and neurological conditions before or concurrent with symptomatic treatment. 4, 3

First-Line Treatment: Benzodiazepines

Lorazepam is the preferred benzodiazepine for treating pediatric catatonia. 2, 5

Dosing and Administration:

• Begin with a lorazepam trial (can serve both diagnostic and therapeutic purposes) 5
• High-dose benzodiazepines are often required and are as effective in children as in adults 3
• Monitor vital signs, airway patency, and level of consciousness during and after administration 2

Expected Response:

• Response to benzodiazepines should be evident relatively quickly 5
• If inadequate response occurs after appropriate benzodiazepine trials, proceed to second-line treatment 6

Important caveat: Children with neurodevelopmental disorders (autism spectrum disorder, Down syndrome, Prader-Willi syndrome) may respond differently or inadequately to benzodiazepines compared to typically developing children, necessitating earlier consideration of ECT. 6

Second-Line Treatment: Electroconvulsive Therapy (ECT)

ECT should be initiated when benzodiazepines fail or in life-threatening situations such as severe malnutrition from food refusal, extreme suicidality, or florid psychosis with catatonia. 1, 2

Specific Indications for ECT:

• Treatment-resistant catatonia after benzodiazepine failure 1, 6
• Malignant catatonia with autonomic instability 1
• Neuroleptic malignant syndrome 1
• Catatonia associated with mood disorders (depression, mania, bipolar disorder) 1
• Catatonia with schizophrenia, particularly when affective symptoms are prominent 1
• Patients unable to tolerate or take medications due to severe incapacitation 1

ECT Protocol:

• Electrode placement: Bilateral electrode placement may be used initially for critically ill patients 2
• Frequency: Treatment begins at two to three times weekly 2
• Anesthesia: Administered by qualified personnel experienced with adolescents; methohexital is commonly used as the anesthetic agent 2
• Muscle relaxation: Achieved with succinylcholine 2

Monitoring During and After ECT:

• Observe seizure duration, airway patency, vital signs, and adverse effects during treatment 2
• Monitor for at least 24 hours after ECT for potential complications such as tardive seizures 2
• Watch for short-term cognitive impairment, anxiety reactions, disinhibition, and altered seizure threshold 1

Evidence of Efficacy:

Recent case series demonstrate marked improvement in children with neurodevelopmental disorders (ages 7-14) who had catatonia and failed benzodiazepine therapy, with no apparent adverse effects from bilateral ECT. 6

Special Populations and Considerations

Catatonia in Neurodevelopmental Disorders:

• Catatonia presents differently in children with autism spectrum disorder, Down syndrome, and other neurodevelopmental conditions 6
• Diagnostic overshadowing may delay recognition 6
• These patients may require earlier progression to ECT due to inadequate benzodiazepine response 6
• Psychomotor regression is a particularly important symptom in this population 3

Catatonia Associated with Schizophrenia:

• First-line benzodiazepines are often insufficient 5
• Certain atypical antipsychotics such as clozapine or quetiapine may be efficient as adjunctive treatment 5
• ECT is indicated when prominent affective symptoms or catatonia persist despite neuroleptic treatment 1

Pregnancy:

• ECT is considered the treatment of choice for catatonia during pregnancy 1

Prognostic Factors

Morbidity and mortality in pediatric catatonia are among the worst in child psychiatry, making prompt recognition and treatment essential. 3

• Early treatment is associated with better outcomes 7
• Untreated catatonia can cause severe medical complications including rhabdomyolysis, renal failure, and death 1, 3
• With prompt diagnosis and treatment, outcomes can be optimized 4

Common Pitfalls to Avoid

• Delaying ECT: Resistance to using ECT or high-dose benzodiazepines exists among child psychiatrists, but this needs to be overcome given the efficacy and severity of untreated catatonia 3
• Missing organic etiologies: Failing to search for underlying medical conditions (present in >20% of cases) may result in missing specific treatments such as immunosuppressor therapy for autoimmune conditions 3
• Diagnostic overshadowing: Attributing symptoms to underlying neurodevelopmental disorders rather than recognizing new-onset catatonia 6
• Inadequate benzodiazepine dosing: High doses are often required and should not be avoided due to unfounded concerns 3