Crossing State Lines: Ethical and Clinical Considerations in Treating a Child With Catatonia

Catatonia is a complex constellation of symptoms presenting with abnormalities in movement and behavior and arises from multiple medical, neurologic, and psychiatric conditions. In recent years, there has been a call to move catatonia from a classifier to a diagnosis of its own in the DSM-5.^1,2 Catatonia is often underdiagnosed in the hospital and carries with it substantial morbidity and mortality.³ Malignant catatonia, characterized by autonomic instability, hyperactivity, mutism, and stuporous exhaustion, is a medical emergency requiring intensive care.⁴ Early diagnosis and treatment are imperative, as untreated malignant catatonia may be fatal in up to 10% to 20% of cases, sometimes only days from onset.⁵ The combination of lorazepam and electroconvulsive therapy (ECT) is a safe and effective treatment for catatonia in both adults and children, although the body of literature pertaining to children remains limited.^6,7 In addition, there are multiple case reports of improvement in catatonia with ECT regardless of etiology.⁸ However, laws in some US states prohibit ECT's use despite evidence of its effectiveness and safety in children and adolescents.⁹ Here, we describe a case presentation that was both prolonged and complicated by state laws pertaining to the use of ECT in children and adolescents.