Antipsychotic Use During Catatonia in Youth with Neurodevelopmental Disorders and Psychotic Symptoms: A 20-Patient...

Catatonia in youth with neurodevelopmental disorders (NDD) may present with co-occurring psychotic symptoms and complicate medication selection, particularly when catatonic symptoms persist despite benzodiazepine treatment. Pediatric evidence guiding antipsychotic use during active catatonia remains limited. We describe antipsychotic medication use and treatment patterns in a 20-patient case series of youth with NDD, catatonia, and psychotic symptoms.

We performed a retrospective chart review of youth treated at Nationwide Children's Hospital between 2017 and 2025. Inclusion required documented NDD, catatonia diagnosed by child and adolescent psychiatrists using the Bush-Francis Catatonia Rating Scale, psychotic symptoms prompting antipsychotic treatment, and receipt of at least one antipsychotic. Clinical Global Impressions ratings were abstracted from clinical documentation, including baseline Clinical Global Impressions-Severity (CGI-S) and Clinical Global Impressions-Improvement (CGI-I) after benzodiazepine treatment and after the first antipsychotic trial, acknowledging that timing was not standardized. Catatonia course, predominant catatonia form, intervention sequencing, adverse effects, electroconvulsive therapy (ECT), clozapine use, and 30-day readmission were abstracted descriptively.

Twenty youth were included (median age 14.0 years; IQR 13.0-15.2), and 50% were female. Numeric full-scale IQ (FSIQ) values were available for 14/20 (70%); median FSIQ was 64.5 (IQR 48.5-69.0; range 43-75), and 13/14 (93%) had FSIQ < 70. Baseline severity was high (median CGI-S 6; range 5-7; n = 20). The catatonia course was acute in 1/20 (5%), subacute in 11/20 (55%), and chronic/relapsing in 8/20 (40%). The predominant catatonia form was mixed in 14/20 (70%), excited/agitated in 5/20 (25%), and hypoactive in 1/20 (5%). After benzodiazepine treatment, 15/20 (75%) had CGI-I ≤ 3, 4/20 (20%) had CGI-I = 4, and 1/20 (5%) had CGI-I ≥ 5. After the first antipsychotic trial, 12/20 (60%) had CGI-I ≤ 3, 6/20 (30%) had CGI-I = 4, and 2/20 (10%) had CGI-I ≥ 5. ECT was used in 12/20 (60%), and clozapine in 7/20 (35%). ECT and antipsychotic treatment were frequently concurrent or occurred within overlapping treatment phases. Thirty-day readmission occurred in 5/20 (25%).

In this cohort, antipsychotic treatment occurred amid high baseline severity, variable catatonia trajectories, and frequent concurrent interventions. Worsening after the first antipsychotic trial was documented in a minority of patients, but findings should be interpreted cautiously given the small sample, retrospective design, absence of a control group, overlapping treatment phases, and the inability to separate medication effects from the underlying illness course. Causal attribution to any single intervention is not possible.