Clinical Differences Between Pediatric and Adult Catatonia
Pediatric catatonia presents with distinct clinical features compared to adults, including more prominent facial involvement, higher rates of neurodevelopmental comorbidities, different emotional triggers, and potentially different treatment responses, requiring heightened clinical suspicion in children with acute behavioral regression.
Presentation Differences
Motor Manifestations
Pediatric catatonia demonstrates more prominent facial hypotonia and perioral involvement, with active movement of the tongue and perioral muscles being characteristic features that may be less evident in adult presentations 1.
Children with catatonia may exhibit motor symptoms that resemble clonic, atonic, or myoclonic seizures, but critically lack loss of consciousness, which can lead to misdiagnosis as a seizure disorder rather than catatonia 1.
Unlike adults, children may experience catatonic episodes without clear emotional triggers, making recognition more challenging since the classic emotion-provoked pattern seen in adults may be absent 1.
Associated Conditions and Comorbidities
Pediatric catatonia occurs with significantly higher rates in children with neurodevelopmental disorders (NDDs), with approximately 50.3% of hospitalized pediatric catatonia patients having an underlying NDD compared to lower rates in adults 2.
Children with autism spectrum disorder, Down syndrome, and Prader-Willi syndrome are at particularly elevated risk for catatonia, and the condition may present as acute behavioral regression in these populations 3.
Catatonia in children frequently co-occurs with bipolar disorder presenting as mixed episodes with irritability and higher rates of comorbid disruptive disorders, whereas adult catatonia more commonly presents in the context of established psychiatric diagnoses with clearer episodic patterns 4.
Diagnostic Challenges
Diagnostic overshadowing is a critical pitfall in pediatric catatonia, where clinicians may attribute catatonic symptoms to the underlying neurodevelopmental disorder rather than recognizing catatonia as a separate, treatable syndrome 3.
The Pediatric Catatonia Rating Scale (PCRS) was specifically modified from adult scales to include urinary incontinence, schizophasia, and acrocyanosis, with withdrawal separated into refusal to eat/drink and social withdrawal, reflecting distinct pediatric presentations 5.
Pediatric catatonia may be underdiagnosed due to challenges in recognition and variability in presentation, with the condition being "hidden in plain sight" among various pediatric disorders 6, 7.
Treatment Differences
Benzodiazepine Response
Children with neurodevelopmental disorders may demonstrate inadequate response to benzodiazepines compared to neurotypical children and adults, requiring earlier progression to electroconvulsive therapy 3.
The median maximum 24-hour benzodiazepine dose (6 mg lorazepam-equivalents) does not differ between pediatric patients with and without NDDs, but response rates vary significantly 2.
Lorazepam remains the first-line treatment at 1-2 mg IV or IM, repeated every 1-2 hours as needed, with identical dosing principles as adults but potentially different efficacy profiles in the NDD population 4, 8.
Electroconvulsive Therapy Utilization
ECT is utilized in only 14.5% of pediatric catatonia hospitalizations, suggesting potential underutilization compared to adult populations where ECT may be employed more readily for treatment-resistant cases 2.
Bilateral ECT should be initiated immediately in pediatric patients with benzodiazepine failure, excited catatonia, malignant catatonia, severe malnutrition, extreme suicidality, or florid psychosis, with treatment frequency of 2-3 times weekly 4, 8.
Children with neurodevelopmental disorders and catatonia show marked improvement after bilateral ECT with no apparent adverse effects, making ECT a critical treatment option when benzodiazepines fail 3.
Treatment Response and Outcomes
Neurotypical pediatric patients have longer hospitalizations (median 5 days) and higher odds of favorable clinical response compared to children with NDDs, with 88.3% probability of achieving at least "much improvement" overall 2.
Patients with non-medical primary diagnoses and an NDD have lower odds of treatment response than neurotypical patients with non-medical primary diagnoses, indicating the need for more aggressive early intervention in the NDD population 2.
Critical Clinical Pitfalls
Recognition Failures
Never attribute acute behavioral regression in children with neurodevelopmental disorders solely to the underlying condition without systematically assessing for catatonia using standardized tools like the PCRS 3, 7.
Avoid confusing parkinsonian side effects from antipsychotics with catatonia, as both present with similar motor symptoms but require fundamentally different management approaches 9.
Do not assume catatonic symptoms will spontaneously resolve without treatment, as life-threatening complications including refusal to eat/drink, severe metabolic derangements, and autonomic instability can develop rapidly 9.
Treatment Errors
Never delay ECT while attempting prolonged benzodiazepine trials in excited catatonia or malignant catatonia in pediatric patients, as these conditions demand immediate definitive treatment regardless of age 4.
Avoid typical antipsychotics in acute pediatric catatonia, as they can worsen the syndrome and precipitate neuroleptic malignant syndrome, though certain atypical antipsychotics like clozapine or quetiapine may be considered as adjunctive treatment in schizophrenia-associated catatonia 8.
Monitoring Requirements
Pediatric patients require identical intensive monitoring as adults during benzodiazepine administration, including vital signs, airway patency, and level of consciousness, with post-ECT observation for at least 24 hours for potential complications 4, 8.
Monitor for autonomic instability (fever, tachycardia, blood pressure changes) as signs of malignant catatonia, which represents a medical emergency requiring immediate bilateral ECT in both pediatric and adult populations 8.