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. Author manuscript; available in PMC: 2025 Dec 12.
Published before final editing as: J Child Adolesc Psychopharmacol. 2025 Dec 1:10.1177/10445463251401519. doi: 10.1177/10445463251401519

Rising Prevalence of Pediatric Catatonia Presenting to Inpatient Care: A Retrospective Analysis

Joshua R Smith a,b, Isaac Baldwin a, Tasia York a,c, Nadia Zaim a,c, James Luccarelli d,e
PMCID: PMC12696821  NIHMSID: NIHMS2127719  PMID: 41334704

Abstract

Purpose:

There has been recent concern for rising rates of catatonia diagnosis in pediatric populations. We set out to determine if rates of catatonia diagnosis have risen at an academic pediatric medical center.

Methods:

The clinical records of 131 patients were obtained from encounters between 2018–2023 in which a diagnosis of catatonia was made in the pediatric emergency department or inpatient medical hospital. Ordinary least squares regression and linear regression analyses were used to determine if the prevalence of catatonia diagnoses, underlying diagnostic category, and Bush-Francis Catatonia Rating Scale scores changed over time.

Results:

A ten-fold increase was observed in catatonia diagnoses between 2018 and 2023. A statistically significant relationship between the year of pediatric catatonia diagnoses was discovered (p=0.01), with an R2 value of 0.83 suggesting approximately 83% of variance can be attributed to the passage of time. Both medical and psychiatric causes of catatonia showed an upward trend over the course of the study period. Average Bush-Francis Catatonia Rating Scale scores showed a slight upward trend but were not statistically significant.

Conclusion:

In this sample of pediatric patients hospitalized at a large academic medical center, the rate of catatonia diagnoses related to both medical and psychiatric causes rose between 2018 and 2023. These data are consistent with previous evidence highlighting an increase in catatonia diagnoses during this period. The COVID-19 pandemic and increasing awareness of catatonia in children may have contributed to this trend. This data supports the importance of investigation into this trend and improving education on catatonia for clinicians and the public.

Keywords: Catatonia, COVID-19 pandemic, Pediatrics, Prevalence study

Introduction:

Catatonia is a neuropsychiatric syndrome with motor, affective, behavioral, and cognitive signs that impacts neurotypical and neurodivergent individuals across the lifespan (Baldwin et al., 2024; Heckers and Walther, 2023; Hirjak et al., 2024; Luccarelli et al., 2024a; Smith et al., 2024c, 2024a, 2025a; Wilson et al., 2025, 2025). Catatonia is often caused by or associated with trauma, stressful life experiences, genetic, medical, neurologic, psychiatric, and neurodevelopmental conditions. In addition, individuals with catatonia are at high risk for admission from the emergency department, frequent symptom relapse, and high support needs (Baldwin et al., 2024; Connell et al., 2023; Hickox et al., 2023; Luccarelli et al., 2022, 2025b; Mahgoub et al., 2025; Pathak et al., 2025; Raffin et al., 2018; Rogers et al., 2023; Shah, 2019; Smith et al., 2025a, 2025b). Compared to adults, children with catatonia are more likely to develop catatonia due to psychosis, encephalitis, or neurodevelopmental disorders (Luccarelli et al., 2024a). Catatonic symptoms can be severe in nature, warranting inpatient medical care due to limited oral intake, autonomic instability, limited physical activity resulting in deep vein thrombosis, or alternatively, intractable aggression or hyperactivity (Becker et al., 2020; Luccarelli et al., 2025a). At its most severe, malignant catatonia may develop, which is a form of catatonia associated with clinically significant autonomic abnormalities, severe symptomology, and a significant risk of mortality (Connell et al., 2023). With or without malignant catatonia, children suffering from catatonia have a significantly elevated risk for morbidity and a 63-fold increased rate of mortality compared to same-age peers (Cornic et al., 2009).

Despite these concerns, the diagnosis of pediatric catatonia can be challenging to make as symptoms may be difficult to detect in children and individuals with baseline neurodevelopmental disorders or may be falsely attributed to another diagnosis. Moreover, symptoms may be subsyndromal and can be missed. Compared to catatonia in adult patients, pediatric catatonia more often presents with negativism, urinary incontinence, and reduced oral intake, all of which may be misconstrued as oppositionality (Benarous et al., 2018; Hickox et al., 2023). In such cases, diagnoses may be delayed, and severe symptoms may persist, leading to functional decline of the child and significant stress upon health systems. If correctly identified, catatonia in children is often rapidly responsive to pharmacotherapy and electroconvulsive therapy (Luccarelli et al., 2024b; Smith et al., 2023, 2024b) and can eventually be managed in the outpatient setting (Luccarelli et al., 2024c; Smith et al., 2025b).

In recent years, clinicians, health systems, and caregivers have raised concerns that the rate of catatonia diagnoses has been increasing following the COVID-19 pandemic. In 2025, Lichtor and colleagues published the first known study to address recent trends in the prevalence of pediatric catatonia. In this analysis, they found a nearly 2.5-fold increase in the incidence of pediatric catatonia from 3.9 to 9.7 per 1000 psychiatry consultations over a 6-year period from 2018 to 2023.(Lichtor et al., 2025; Soe et al., 2025) As their study occurred at a single site, we have conducted a secondary analysis of our previous publication on inpatient hospitalizations for pediatric catatonia (Luccarelli et al., 2025a) to ascertain if this finding was also present at our institution and to add to the pediatric catatonia literature broadly. We hypothesized that our data would show a similar increase in the prevalence of pediatric catatonia diagnoses over a similar time frame.

Methods:

Data Source:

This is a secondary analysis of our previous publication, which included data from both Massachusetts General Hospital and Vanderbilt University Medical Center (VUMC) (Luccarelli et al., 2025a). The analysis presented here includes only data from VUMC. Specifically, clinical records from VUMC were queried for patients between 1/1/2018 and 12/31/2023 who were 18 years of age or younger and were diagnosed with catatonia in the medical setting (emergency department or inpatient pediatrics). Patients were included in this analysis if their diagnosis was confirmed via assessment with the Bush-Francis Catatonia Rating Scale (BFCRS). The BFCRS (Bush et al., 1996), the most cited rating scale in the field of catatonia, (Weleff et al., 2023) consists of a 14-item Bush-Francis Catatonia Screening Item and a full 23-item BFCRS which measures a greater number of signs (Bush et al., 1996). Data on the total number of patients under the age of 18 who admitted to the medical hospital were also obtained via EPIC SlicerDicer (EPIC Systems Corporation, 2021). This study was approved by the Vanderbilt University Medical Center Institutional Review Board (#230097) with a waiver of informed consent from participants, as the data collected was part of routine clinical activities.

Data extraction:

Age, sex, race, ethnicity, BFCRS scores, length of hospitalization, discharge disposition, mortality, benzodiazepines and other pharmacologic treatments, use of electroconvulsive therapy (ECT) and clinical diagnoses were extracted from the medical record and are fully reported in our previous manuscript (Luccarelli et al., 2025a). In the present analysis, we also collected the year in which catatonia was diagnosed. Additionally, we categorized the underlying cause of catatonia into six separate categories based on Diagnostic and Statistical Manual, Fifth Edition (American Psychiatric Association, 2022): unspecified catatonia, neurodevelopmental disorder, medical, psychiatric, substance-induced, and delirium. These were determined based on review of the psychiatry documentation, meaning the underlying cause of catatonia was identified by the treating psychiatric providers.

Statistical Analysis:

We conducted an ordinary least squares (OLS) regression to determine if there was a statistically significant correlation between BFCRS scores and the year in which pediatric catatonia was diagnosed as a measure of the change in frequency of pediatric catatonia diagnoses. This analysis was conducted to determine if there was a difference across individual years as assessments were likely completed by different psychiatrists.

Results:

Demographics and Initial Catatonia Scoring:

131 patients were included in our analysis. Of the 131 patients, 71 (54.2%) were male and 60 (45.8%) were female. The mean age when the patient was first treated for pediatric catatonia was 13.4 years (SD=3.4), with a median of 14 years. The mean BFCRS score was 15.8 (SD=5.9), with a median score of 15.

Diagnoses of Pediatric Catatonia by Year:

Between 2018 and 2023, a total of 131 pediatric catatonia diagnoses were recorded (Table 1). In 2018, there were 5 diagnoses, representing 3.8% of the total and corresponding to a hospitalization rate of 0.02 per 100 admissions. This increased to 9 diagnoses in 2019 (6.9%), with a rate of 0.04 per 100 admissions. In 2020, 10 diagnoses were recorded (7.6%), and the rate rose slightly to 0.05. The upward trend continued in 2021 with 13 diagnoses (9.9%) and a rate of 0.06. A marked increase occurred in 2022, with 43 diagnoses (32.8%) and a rate of 0.18. The highest number was observed in 2023, with 51 diagnoses (38.9%) and a rate of 0.22. These data reflect a substantial rise in both the number and rate of pediatric catatonia diagnoses over the six-year period. Of note, only one patient (0.8%) had a COVID-19 diagnosis during the hospitalization.

Table 1:

Diagnoses of Pediatric Catatonia by Year

Total Diagnoses of Pediatric Catatonia (N) % of Total Diagnoses Total admissions for individuals under 18 years Rate of hospitalizations for pediatric catatonia
2018 5 3.8 20,406 0.02
2019 9 6.9 20,761 0.04
2020 10 7.6 18,522 0.05
2021 13 9.9 22,268 0.06
2022 43 32.8 24,102 0.18
2023 51 38.9 23,693 0.22
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As shown in Figure 1, an ordinary least squares (OLS) regression analysis revealed a strong positive relationship between year and the rate of pediatric catatonia diagnoses. The model yielded an R2 value of 0.8278, indicating that approximately 83% of the variance in diagnosis rates can be explained by the passage of time. The coefficient for the year variable (β = 0.0004) suggests that the rate of diagnoses increased by an average of 0.0004 per year. This trend was statistically significant, with a p-value of 0.0118, indicating that the observed increase is unlikely to be due to random variation. These findings support the conclusion that the rise in diagnosis rates over time reflects a meaningful and consistent upward trend.

Figure 1:

Figure 1:

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Linear Regression for Yearly Rate of Pediatric Catatonia Diagnoses

Diagnoses of Pediatric Catatonia by Year per Diagnostic Category:

The underlying diagnoses associated with pediatric catatonia varied across the years from 2018 to 2023 and are outlined in Table 2. Cases of unspecified catatonia were present each year, starting with 3 cases in 2018 and 2019, dropping to 1 in 2020, none in 2021, then rising to 4 in 2022 and peaking at 22 in 2023. Pediatric catatonia attributed to neurodevelopmental disorders were initially rare, with only 1 case in 2018 and none in 2019 or 2020. However, there was an increase in 2021 with 3 cases, followed by an increase to 21 in 2022, before decreasing to 4 in 2023.

Table 2:

Diagnoses of Pediatric Catatonia by Year and Underlying Diagnosis

Underlying Diagnosis 2018 2019 2020 2021 2022 2023
Unspecified Catatonia 3 3 1 0 4 22
Neurodevelopmental Disorder 1 0 0 3 21 4
Medical 0 2 4 4 1 8
Psychiatric 1 3 5 6 16 16
Substance Induced 0 0 0 0 1 0
Delirium 0 1 0 2 0 1
Total Diagnoses of Pediatric Catatonia 5 9 10 13 43 51
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Medical causes of catatonia were first recorded in 2019 with 2 cases, increasing to 4 in both 2020 and 2021, then dropping to 1 in 2022 and rising again to 8 in 2023. Psychiatric causes showed a consistent upward trend from 1 case in 2018 to 3 in 2019, 5 in 2020, 6 in 2021, and 16 in both 2022 and 2023. Substance-induced catatonia was rare, with only a single case reported in 2022. Similarly, delirium-related catatonia was infrequent, with one case each in 2019, 2021, and 2023.

Correlation between Bush Francis Catatonia Rating Scale Scores and Year of Pediatric Catatonia Diagnoses:

A linear regression analysis was conducted to examine the relationship between evaluation year and mean BFCRS scores (Figure 2). The model yielded a slope of 0.38, indicating a slight upward trend in BFCRS scores over time. However, the R2 value was 0.08, suggesting that only 8% of the variance in BFCRS scores can be explained by the year of diagnosis. Moreover, the p-value associated with the year variable was 0.5873, indicating that the observed trend is not statistically significant. These findings suggest that there is no meaningful linear relationship between the year of diagnosis and overall severity of catatonia, as measured by the BFCRS.

Figure 2:

Figure 2:

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Linear Regression for Mean BFCRS Score by Year

Discussion:

In this single site retrospective analysis of 131 pediatric patients, we found greater than a 10-fold increase in the number of pediatric catatonia diagnoses between 2018 and 2023. This is the second manuscript to demonstrate a significantly elevated rate of pediatric catatonia diagnoses since 2018. We also set out to determine if there was a correlation with the BFCRS scores and the year in which the pediatric catatonia diagnosis was made. No statistically significant relationship was found. This lack of variation in BFCRS scoring suggests that the manner in which cases of pediatric catatonia were assessed did not change year over year. The combination of these two findings supports the elevated prevalence found in this manuscript as well as by Lichtor and colleagues(Lichtor et al., 2025).

Notably, we also found a significantly elevated overall rate of pediatric catatonia diagnoses in the diagnostic categories of unspecified catatonia, neurodevelopmental disorders, medical, and psychiatric etiologies. However, there were minimal increases in the number of substance-induced or delirium-induced catatonia cases over the same period of time. While the overall prevalence is low, the delirium finding is relevant as Diagnostic and Statistical Manual, Fifth Edition (American Psychiatric Association, 2022) has historically stated that delirium and catatonia may not be co-morbid. However, this manuscript and others suggest that catatonia may, in fact, overlap clinically or co-occur in individuals (Luccarelli et al., 2025d). In addition, the elevated rate of catatonia in neurodevelopmental disorders also supports previous research connecting autism and genetic syndromes with elevated rates of catatonia (Baldwin et al., 2024; Shillington et al., 2023; Smith et al., 2024a, 2025a; Zappia et al., 2024).

Given that both Lichtor’s study and ours occurred over the COVID-19 pandemic, it is possible that the psychological and biological influences of the pandemic contributed to the rate of pediatric catatonia, similar to neuropsychiatric symptomatology which presented during other pandemics such as the Spanish Flu (Rogers et al., 2024). This is especially notable, as there was a rise in catatonia due to underlying medical etiologies in our study as well as Lichtor’s. However, it is worth noting that only one patient in our cohort was diagnosed with COVID-19 during their hospitalization. Another point of consideration is the increasing awareness of catatonia presenting in children broadly as well as in autism and other neurodevelopmental disorders, which also likely contributed (Benarous et al., 2016; Vaquerizo-Serrano et al., 2022). Of note, there is growing literature addressing the interplay of stressful life events and catatonia prevalence, especially for autistic individuals (Öksüzoğlu et al., 2025). Increased recognition of catatonia in this population, along with increased social isolation in the setting of the COVID-19 pandemic, may also be a contributing factor.

Strengths of the study include the large sample size relative to previous publications in pediatric catatonia. Inclusion criteria were broad and included a wide range of co-morbidities, representing a real-world clinical sample. The limitations of our study include the single-site nature of its design. Specifically, sampling bias may have occurred which may explain the large difference in increasing overall prevalence rates between this manuscript and that written by Lictor and colleagues (Lichtor et al., 2025). As patients could only be included in the cohort if diagnosed with catatonia, the rate of under-diagnosis or the potential treatment-responsiveness of unidentified cases of catatonia cannot be determined. Additionally, the BFCRS used for catatonia assessment in this study has not been specifically validated for use in pediatric or neurodivergent patients, which should be considered when comparing data across studies. Furthermore, results from these academic health systems may not translate to other healthcare settings or to populations of different sociodemographic groups. This final limitation is particularly relevant given that our institution is a large academic center with multiple sub-specialists who routinely provide care for catatonic children and have created a multi-disciplinary roadmap for this condition (Smith et al., 2024d). Moreover, previous research has demonstrated a higher prevalence of catatonia in both adults and children presenting to the emergency departments of academic medical centers compared to other hospitals (Luccarelli et al., 2025b). Thus, as our data is obtained from such an institution, the possibility of observational bias is a critical component in assessing our data. This may partially explain the significant increase in pediatric catatonia cases presenting to our institution.

Future studies may consider additional screening tools, including the Catatonia Quick Screen (Luccarelli et al., 2025c) given that catatonia can be easily overlooked in children and autistic individuals as they more often present with symptoms which are more behaviorally challenging. In Lichtor’s paper, it is also highlighted that there is a great degree of variability in the rates in which medical workup (laboratory studies, imaging, and procedural tests) were performed (Lichtor et al., 2025). Thus, we encourage future research and overall clinical care to include a robust and comprehensive assessment as outlined in the first single-institution standardized approach published by Smith and colleagues (Smith et al., 2024d). Lastly, future work should include long term epidemiological research at a population level to determine if a true rise in pediatric catatonia prevalence is present.

In conclusion, catatonia is a severe neuropsychiatric syndrome associated with significant morbidity and mortality in children. Based on our data, as well as that of Lichtor and colleagues, the frequency of catatonia presenting to children’s hospitals is on the rise. This pattern is likely multifactorial. Regardless, it warrants further investigation as well as education of the general population and medical community on catatonia. Such efforts are likely to lead to improved outcomes for these children.

Funding:

Sources of support included grants from Eunice Kennedy Shriver National Institute of Child Health and Human Development (1P50-HD103537; JRS), and National Institute of Mental Health (R01-MH135028; JRS). No funding agencies had any role in study design, writing of the report, or data collection, analysis, or interpretation.

Conflicts of Interest Statement:

JRS receives funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the American Academy of Child and Adolescent Psychiatry, National Institute of Mental Health, Axial Therapeutics, Vanda Pharmaceuticals, Bristol Myers Squibb, Johnson and Johnson, and Roche. JL receives funding from Harvard Medical School, the Rappaport Foundation, the American Academy of Child and Adolescent Psychiatry, and the Foundation for Prader-Willi Research. He holds equity and has received consulting income from Revival Therapeutics, Inc, and has received cash compensation for consulting from Soleno Therapeutics.

Abbreviations:

BFCRS

Bush-Francis Catatonia Rating Scale

VUMC

Vanderbilt University Medical Center

ECT

Electroconvulsive therapy

OLS

Ordinary least squares

Footnotes

Ethical approval for human patients:

This study was reviewed by the Vanderbilt University IRB (#170317) with a waiver of informed consent from participants as data which was collected was based on routine clinical activities.

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