Pediatric Catatonia
…the prevalence of catatonia among the general pediatric population has not been established, it is estimated to be between 0.6% and 17…
Case
17 yo female with no significant medical history presents to the emergency department with behavior change. The patient, who was previously talkative, social, and interactive, has been more withdrawn, isolating in her room for 3 weeks. She has had a decreased intake of food and fluids during this time. Family reports that the patient has a history of near daily cannabis use.
On exam, her vital signs are stable and reassuring. She is awake, but does not respond to most questions. She appears anxious. She is following commands and answers to yes and no questions by shaking and nodding her head. Neurologic exam is nonfocal and without rigidity. She ambulates slowly with normal gait. She shrugs when asked about her mood. She denies SI, HI, and auditory/visual hallucinations.
Labs
CBC: normal
CMP: normal
Ck: normal
EtOH: negative
UDS: +Cannabinoids
Diagnosis
Catatonia
Background
Catatonia is a syndrome that consists of motor and behavioral signs and symptoms in the setting of neurochemical insult. It can be seen with psychiatric, neuromedical, and substance induced conditions. Though the prevalence of catatonia among the general pediatric population has not been established, it is estimated to be between 0.6% and 17% among child and adolescent psychiatric inpatients [1]. Pediatric patients with catatonia are mostly likely to have a primary diagnosis of psychotic disorder (18.3%) or a neurologic, developmental, and inflammatory illness, such as autoimmune and infectious processes (11.8%) [2]. In comparison, adult patients have a higher proportion of underlying mood disorders, especially bipolar disorder [4]. Common comorbidities among pediatric patients that develop catatonia include substance use disorder, especially cannabis, and Autism Spectrum Disorder (ASD). Data suggest that nearly 4-17% of all individuals with ASD will have an episode of catatonia during adolescence or adulthood [5].
The medical complications associated with catatonia include aspiration, pneumonia, infection, electrolyte and metabolic derangements due to underlying illness, whether acquired or genetic. These patients also have increased clotting risk and renal dysfunction Pediatric catatonia and its sequelae are associated with 6000% increased mortality relative to age matched controls, over a 4 year follow-up period [2].
Pathophysiology
While the pathophysiology of catatonia remains unclear, it is well accepted that catatonia reflects an abnormality of the neurocircuitry associated with movement. It involved imbalances of several neurotransmitters, including GABA, glutamate, and dopamine. GABA agonists, such as benzodiazepines, are well known to improve catatonia, while deficiency in GABA due to withdrawal from benzodiazepines may worsen the condition. It is noted that dopamine inhibition may exacerbate catatonia, while agents that augment dopamine (ex. Levodopa, bromocriptine) may improve catatonia. Inhibition of glutaminergic NMDA receptors (ex. ketamine, memantine) has been found to improve catatonia [10].
Types of catatonia
There are three types of catatonia: hypokinetic, hyperkinetic, and malignant catatonia. Generally speaking, in hypokinetic catatonia patients appear obtunded and move/speak slowly. In hyperkinetic catatonia, patients have prolonged periods of agitation. In comparison to mania, the hyperactivity seen in hyperkinetic catatonia is not goal directed. Malignant catatonia is an acute life threatening subtype of catatonia that is characterized by autonomic instability (fever, tachycardia, and labile blood pressure), delirium, and rigidity in addition to behavior and movement changes [12].
Diagnosis
Prompt diagnosis and treatment of catatonia is paramount as increased time to diagnosis is associated with greater treatment resistance and fatality [5]. Pediatric catatonia is both underdiagnosed and undertreated.
The DSM-V criteria defines catatonia as the presence of three or more of the following: catalepsy (passive induction of positions held against gravity), waxy flexibility, stupor, mutism, agitation, echolalia (repeating words), echopraxia (mimicking movements), or posturing. The Bush-Francis Catatonia Rating Scale (BFCRS) [7] is a validated screening tool used for catatonia. It is a 23 item rating scale with a truncated 14 item screening instrument evaluating defined signs of catatonia found in published sources.
Catatonia Exam
For reference, a video examination for catatonia is available here.
Pediatric Catatonia rating scale
A Pediatric Catatonia Rating Scale, validated by Benarous et. al. [13], is a scale modified from BFCRS. There are 6 added symptoms, which are more appropriate to assess in pediatric cases. These symptoms were added based on the analysis of 463 catatonic cases pooled from seven studies and review of historical description of pediatric catatonia.
Refusal to eat/drink
Social withdrawal
Incontinence
Acrocyanosis (persistent, painless dusky/blue color of hands, feet, or face)
Schizophasia (aka word salad)
Automatic compulsive movements
Alternatives conditions to rule out/consider
Alternative conditions, which may mimic hypokinetic catatonia and should be ruled out or assessed prior to making the diagnosis include hypoactive delirium, akinetic mutism, locked in syndrome, and functional coma. Particularly important to consider in the pediatric population are nonconvulsive status epilepticus, meningitis/encephalitis, and major depression.
Alternative conditions that may mimic hyperkinetic catatonia include agitated delirium, acute mania, complex partial seizures and nonconvulsive status epilepticus, and akathesia.
Conditions that may mimic malignant catatonia include neuroleptic malignant syndrome (NMS) and meningitis.
Medical Work-up
Thorough medication and substance use review
Lab work: electrolytes, cortisol, TSH, CK, LFTs, and additional toxicology work-up.
Neuroimaging: CT and/or MRI to assess for underlying CVA or structural brain lesions.
Lumbar Puncture: Evaluate for infection (consider autoimmune encephalitis panel)
EEG: Assess for underlying epilepsy and delirium (normal in patients with catatonia)
Diagnostic Challenge
Lorazepam: Administer 1-2mg IV lorazepam and look for improvement in symptoms within 30 minutes. It is important to note that improvement with benzodiazepines may not be specific for catatonia, as both epileptic and withdrawal conditions will improve with administration. Lorazepam can be continued if clinical suspicion remains high for catatonia.
Ketamine: In adults, low doses of Ketamine appear to improve symptoms of catatonia, ~3mg IV every few minutes to a maximum dose of 15-20mg [9]. There are no case studies to support the use of ketamine in the pediatric population.
Treatment
Treat the underlying cause.
Stop anti-dopaminergic agents (ex. antipsychotics) and restart dopamine agonists if recently discontinued.
Benzodiazepine: IV lorazepam is treatment of choice, especially effective when the challenge dose was given. It is estimated that the mean daily dose of lorazepam in pediatric patients with catatonia is 5.35 ± 3.64 mg/day, but may reach as high as 15 mg/day in some patients. Patients with autism spectrum disorder may require higher doses, and have been shown to reach as high as 30 mg/day [13].
Electro Convulsive Therapy (ECT): ECT is FDA approved for the treatment of catatonia in patients greater than 13 years of age. Utilization of ECT in the pediatric population is ~5.3%, compared to 8.3% of patients >18 yo [2]. ECT is effective in 85% of cases, typically done ~3x/week. It is also the treatment of choice in malignant catatonia, which has a lower response rate to benzodiazepines.
Benzodiazepines +ECT: Together, these treatments have synergistic effects. It may be necessary to reduce benzodiazepine dosing in order to reduce seizure threshold.
Treatment to reduce complications: DVT prophylaxis, fluid resuscitation as needed for rhabdomyolysis, and nutritional support.
Case conclusion
Given concern for catatonia, the patient was given lorazepam 2mg IV with improvement in her symptoms. She was admitted to the pediatric hospitalist service for ongoing management and work-up. She was initially treated with 2mg lorazepam q8hr, and successfully tapered down. She did not require ECT. Ultimately, she was diagnosed with unspecified psychotic disorder and discharged on sertraline with psychiatric outpatient follow-up.
Resources
Cohen HD, Flament M, Dubos PF, Basquin M. Case series: catatonic syndrome in young people. J. Am. Acad. Child Adolesc. Psychiatry, 38 (8) (1999), pp. 1040-1046.
Luccarelli J, Kalinich M, Fernandez-Robles C, Fricchione G, Beach SR. The Incidence of Catatonia Diagnosis Among Pediatric Patients Discharged From General Hospitals in the United States: A Kids' Inpatient Database Study. Front Psychiatry. 2022 Apr 29;13:878173. doi: 10.3389/fpsyt.2022.878173. PMID: 35573347; PMCID: PMC9106281.
Ahmed GK, Elbeh K, Karim AA, Khedr EM. Case report: catatonia associated with post-traumatic stress disorder. Front Psychiatry. (2021) 12. 10.3389/fpsyt.2021.740436
Grover S, Chakrabarti S, Ghormode D, Agarwal M, Sharma A, Avasthi A. Catatonia in inpatients with psychiatric disorders: a comparison of schizophrenia and mood disorders. Psychiatry Res. (2015) 229:919–25. 10.1016/j.psychres.2015.07.020
Dhossche DM. Decalogue of catatonia in autism spectrum disorders. Front Psychiatry. (2014) 5:157. 10.3389/fpsyt.2014.00157
Fink M, Taylor MA. Catatonia: A Clinician's Guide to Diagnosis and Treatment. Cambridge: Cambridge University Press; (2006). 276 p.
Bush G, Fink M, Petrides G, Dowling F, Francis A. Catatonia. I. Rating scale and standardized examination. Acta Psychiatr Scand. 1996 Feb;93(2):129-36. doi: 10.1111/j.1600-0447.1996.tb09814.x. PMID: 8686483.
Benarous X, Raffin M, Ferrafiat V, Consoli A, Cohen D. Catatonia in children and adolescents: New perspectives. Schizophr Res. 2018 Oct;200:56-67. doi: 10.1016/j.schres.2017.07.028. Epub 2017 Jul 25. PMID: 28754582.
Iserson KV, Durga D. Catatonia-Like Syndrome Treated With Low-Dose Ketamine. J Emerg Med. 2020 May;58(5):771-774. doi: 10.1016/j.jemermed.2019.12.030. Epub 2020 Jan 27. PMID: 32001125.
Wilson JE, Oldham MA, Francis A, Perkey D, Kramer E, Jiang S, Yoon J, Beach S, Fricchione G, Gunther M, Ha J, Luccarelli J, Rosen J, Hamlin D, Dragonetti JD, Gerstenblith A, Stewart AL, Sole J, Bourgeois JA. Catatonia: American Psychiatric Association Resource Document. J Acad Consult Liaison Psychiatry. 2025 Jul-Aug;66(4):277-299. doi: 10.1016/j.jaclp.2025.05.001. Epub 2025 May 12. PMID: 40368005.
Beach A, Reddick B, Stern T. Catatonia, Neuroleptic Malignant Syndrome, and Serotonin Syndrome. Massachusetts General Hospital Psychiatry Update and Board Preparation, Third Edition. 2012.
Fink M and Taylor MA. The catatonia syndrome: forgotten but not gone. JAMA Psychiatry. 2009;66(11):1173-1177. doi:10.1001/archgenpsychiatry.2009.141
Benarous X, Consoli A, Raffin M, Bodeau N, Giannitelli M, Cohen D, Olliac B. Validation of the Pediatric Catatonia Rating Scale (PCRS). Schizophr Res. 2016 Oct;176(2-3):378-386. doi: 10.1016/j.schres.2016.06.020. Epub 2016 Jul 1. PMID: 27377978.
Author
Jenny McManus, MD is a fourth-year emergency medicine resident at Brown University Health/Rhode Island Hospital.
Faculty Reviewer
Alicia Genisca, MD Assistant Professor, Emergency Medicine & Pediatrics, Clinician Educator
Resident reviewer
Maggie Stark, DO, MS is a third-year emergency medicine resident at Brown University Health/Rhode Island Hospital.