Rethinking Catatonia in Neurodevelopmental Conditions: Toward a Refined Typology and Research Framework

Catatonia is a transdiagnostic syndrome observed across psychiatric, medical, and developmental disorders. In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), it is not classified as a stand-alone disorder but as a specifier or syndrome that accompanies other conditions. This review examines the current state of knowledge on catatonia in children, adolescents, and individuals with neurodevelopmental disorders, particularly autism spectrum disorder and intellectual developmental disorders. Several DSM-5-TR criteria overlap with baseline behaviors in these populations, creating a risk of false-positive diagnoses. To improve specificity, a refined framework that requires at least 2 of 5 core signs-stupor/immobility, new-onset mutism, posturing or catalepsy with waxy flexibility, severe negativism or withdrawal, and stimulusindependent excitement/agitation-each demonstrably new or worsened from baseline is proposed. The Bush-Francis Catatonia Rating Scale and its Pediatric Catatonia Rating Scale adaptation is reviewed, highlighting their limitations in developmental contexts. Catatonia typologies relevant to neurodevelopmental conditions are also outlined, the cautious use of the lorazepam challenge test is discussed, and converging neurobiological evidence implicating gamma-aminobutyric acid, glutamate, dopamine, cortico-striato-thalamo-cortical circuitry, and immune mechanisms is summarized. Future directions include psychometric validation of pediatric tools, empirical item reduction, integration of biomarkers, and treatment prediction studies to refine developmental assessment and clinical care.