Pediatric Catatonia: Improving Recognition and Treatment Outcomes

December 9, 2025

Ruta Nonacs, MD PhD

Despite the significant morbidity associated with catatonic symptoms, catatonia remains underrecognized and understudied, especially in children.

Catatonia is a complex neuropsychiatric syndrome characterized by psychomotor disturbance, affective dysregulation, changes in speech and behavior, and autonomic dysfunction. While catatonia has long been recognized in adults, it remains an understudied condition in the pediatric population.

In children and adolescents, catatonia may occur in the context of medical illness; however, it appears that neurodivergent children, as well as neurotypical children with psychiatric disorders, are at higher risk of catatonia. Although uncommon, pediatric catatonia has been associated with significant morbidity and mortality. In research from a multicenter study of catatonia in neurodivergent and neurotypical patients, James Luccarelli, MD, DPhil, and colleagues examine the clinical features and treatment outcomes of pediatric catatonia.

Clinical Presentation

Although the features of catatonia have been relatively well described in adults, we know less about the clinical presentation in pediatric patients with catatonia. In a multisite retrospective cohort study carried out at two academic medical centers, the research team evaluated a cohort of 143 patients aged 18 years and younger with a clinical diagnosis of catatonia.

The median age was 15 years (interquartile range: 13–16), and 66 (46.2%) patients were female. Neurodevelopmental disabilities (NDDs) were present in 55 (38.5%) of the patients.

Pediatric patients presented with, on average, 6.0 ± 2.1 signs of catatonia identified using the Bush Francis Catatonia Rating Scale (BFCRS), with a mean BFCRS score of 15.0 ± 5.9. Among the 23 items identified using the BFCRS, six were present in more than half of the patients: staring, mutism, immobility/stupor, withdrawal, posturing/catalepsy, and rigidity. Four items were observed in less than 20% of the cases: waxy flexibility, mitgehen (tendency to passively follow the examiner’s movements), gegenhalten (involuntary resistance to passive movement), and grasp reflex.

Compared to neurotypical youth with catatonia, patients with NDDs and catatonia were younger (median of 14 vs. 15 years), were more likely to be male (63.9% vs. 47.6%), and were less likely to be Hispanic (8.4% vs. 22.0%). In addition, children with NDDs had higher initial BFCRS scores (median of 17 vs. 14).

Treatment and Clinical Outcomes

In another study, Luccarelli and colleagues examined treatment outcomes in a multisite sample of 165 hospitalized pediatric patients with catatonia drawn from the same two academic medical centers. Nearly all (164 of 165) patients were treated with a benzodiazepine, with a median maximum 24‑hour dose of 6 mg lorazepam equivalents. The dose did not differ for patients with and without NDDs. Of the patients who were treated with a benzodiazepine, 21.5% required treatment with more than one benzodiazepine, most often longer‑acting agents such as clonazepam and diazepam. The majority of patients requiring treatment with multiple benzodiazepines had a diagnosis of autism spectrum disorder.

In this cohort, 14.5% of pediatric patients with catatonia required treatment with ECT.

The median length of medical hospitalization was 5 days, and hospitalizations were longer in neurotypical patients than in patients with NDDs (median of 8 days vs. 5 days for those with NDDs). By the time of discharge, most patients remained on a benzodiazepine, although at lower doses (median of 3 mg lorazepam equivalents per day). The probability of observing at least “much improvement” (CGI < 3) was 88.3% (95% CI: 82.4% to 92.3%); however, children with an NDD diagnosis had lower odds of clinical response.

Improving Recognition of Catatonia

Despite the significant morbidity associated with catatonic symptoms, catatonia remains underrecognized and understudied, especially in children. The studies included here indicate that with treatment, pediatric patients with catatonia experience substantial improvement. Nearly all patients were treated with benzodiazepines. Severity of catatonic symptoms (as measured using BFCRS scores at baseline) did not correlate with hospital length of stay or odds of clinical improvement.

Treatment course and outcomes were different for neurotypical children versus those with NDDs. Children with NDDs were more likely to receive multiple benzodiazepines and were less likely to recover fully from their illness. Additionally, children with NDDs had shorter lengths of stay, suggesting that they may not be fully treated or may be discharged at an earlier stage in treatment. Further research under controlled conditions is needed to optimize and ensure equitable and effective treatment for youth with NDDs.

This research also highlights the importance of ECT as a treatment option for catatonia in children. ECT was utilized in 14.5% of pediatric patients with catatonia. While ECT is an effective treatment for catatonia, particularly when symptoms are refractory to medication treatment, many states still limit the use of ECT in pediatric patients.

Catatonia is frequently overlooked in pediatric patients, and delays in recognition and treatment may result in increased morbidity and unnecessary medical procedures. The diagnosis of catatonia is also more complicated in individuals with baseline impairments in communication, such as those seen in children with neurodevelopmental disorders. Given that about half of pediatric patients hospitalized with catatonia have neurodevelopmental disorders, there is an urgent need to increase awareness of catatonia and to develop screening tools that can be used to help clinicians recognize and manage catatonia.

There does not yet exist a widely accepted screening instrument for catatonia. Luccarelli and colleagues have developed an abbreviated screen for catatonia, the Catatonia Quick Screen (CQS). Compared to the Bush Francis Catatonia Screening Instrument (BFCSI), which requires the clinician to identify two signs of catatonia from a list of 14 possible signs, the CQS requires assessment of just four signs (excitement, mutism, staring, and posturing), with only one of the four required to screen as positive, and has a sensitivity of 97%. Although the CQS does not serve as a definitive diagnostic test, this high‑sensitivity tool could be easily used to rule out catatonia and is well suited to quickly identify catatonia in both neurotypical and neurodivergent pediatric patients.

Other MGH Psychiatry researchers involved in this project (in alphabetical order) include Jacqueline Clauss, Gregory Fricchione, Catherine Fuchs, and Tasia York.