Catatonia is a complex disorder covering a range of abnormalities of movement, posture, speech and behavior associated with under-activity as well as over-activity. Research and clinical evidence reveals that some children with Autism Spectrum Disorders (ASD), including Asperger’s and High Functioning Autism, develop a complication characterized by catatonic and Parkinsonian features.
In children with ASD, catatonia is shown by the onset of any of the following traits:
- increased slowness affecting movements and/or verbal responses
- increased reliance on physical or verbal prompting by others
- increased passivity and apparent lack of motivation
- Parkinsonian features (e.g., freezing, excitement and agitation, a marked increase in repetitive and ritualistic behavior)
- difficulty in initiating, completing, and inhibiting actions
Behavioral and functional deterioration in the teenage years is common among young people with ASD. When parents notice a deterioration or an onset of new behaviors, it is important to consider the possibility of catatonia as an underlying cause. Early recognition of problems and accurate diagnosis are important, because it is easiest to manage and reverse the condition in the early stages. Catatonia is a serious condition that can become more severe. This risk increases the longer the condition is left untreated, and it becomes more difficult to reverse the more severe it becomes. Catatonia is distressing for the ASD child, which can cause additional behavioral disturbances.
Autism-related catatonia looks quite different from classic catatonia. It occurs across a spectrum from mild to severe. In mild and moderate cases, moms and dads often describe their ASD teenagers as “slowing down” or appearing depressed. Sometimes, these teens become stuck when trying to initiate a movement (e.g., he or she may walk up to a doorway and then freeze before stepping over the threshold). Severe cases of autism-related catatonia look a lot like classic catatonia, with the youngster almost completely shutting down.
Autism-related catatonia also produces changes in movement patterns, which can include a brief “freeze” during actions, bursts of hyperactivity, difficulty coming to a stop, incontinence, marked reduction in speech, odd gait, and stiff posture.
One of the reasons autism-related catatonia went unrecognized for so long is because many of its symptoms overlap with those of autism. Thus, the “red flag” for moms and dads is a “marked change in behavior.” What’s lost is the ability to turn intentions into action.
There is little information on the cause or effective treatment of catatonia. In one study of referrals who had ASD, it was found that 17% of all those aged 15 and over had catatonic and Parkinsonian characteristics of sufficient degree to severely limit their mobility, use of speech, and ability to carrying out daily activities. It was more common in those with mild or severe learning disabilities, but did occur in some who were high-functioning.
Autism-related catatonia appears to result from a depression in the GABA neurotransmitter system. GABA is a brain neurotransmitter (i.e., it enables nerves in the brain to send messages to one another). One medication used to treat autism-related catatonia is the GABA-stimulating medicine called lorazepam (trade name Ativan). With true autism-related catatonia, positive response to such treatment are often seen within an hour or so. This lasts for up to several hours. Thus, a positive response (with the ASD child showing improved spontaneous movement) helps confirm the diagnosis. For many of these kids, this type of medicine is also an effective long-term treatment. For severe cases, treatment options include electroconvulsive therapy, which seems to act like a “brain reboot” that helps get the child moving and eating again.
Given the scarcity of information in the literature, as well as the potential adverse side effects of medical treatments, it is important to recognize and diagnose catatonia as early as possible so that environmental, cognitive and behavioral methods of the management of symptoms and underlying causes can be implemented. Detailed psychological assessment of ASD children, their lifestyle, environment, circumstances, pattern of deterioration and catatonia are needed to design an individual program of management. When evaluating for catatonia, the doctor needs to understand what the child was like before concerns arose. How smooth were his movements? What were his interests and abilities? How did they change?