Electroconvulsive Therapy in a Child Suffering from Acute and Transient Psychotic Disorder with Catatonic Features.

Electroconvulsive therapy (ECT) is a recognized and effective treatment in adults for several psychiatric disorders. However, the lack of knowledge and experience with the use of ECT among child and adolescent psychiatrists is an obstacle to its appropriate use. Treatment using ECT in children of prepubertal age has been less reported. We present a case of 10-year-old child with a diagnosis of acute and transient psychotic disorder with catatonic features, where we have used ECT successfully.

INTRODUCTION

It is well-known that electroconvulsive therapy (ECT) is a safe and effective treatment for various mental disorders in adults. However in children and adolescents ECT is used almost exclusively as a treatment of last resort when other treatments have failed and when the patient's symptoms are incapacitating or life-threatening. In 2004 American Academy of Child and Adolescent Psychiatry published the criteria and parameters for conducting ECT in children and adolescents.[1] Following this, many case reports have advocated its use in the adolescent population.[23] However, there are occasionally few reports on using ECT in children that show the overall efficacy and safety of this method.[45] Hence, we present a case of 10-year-old child with a diagnosis of acute and transient psychotic disorder with catatonic features, where we have used ECT successfully.

CASE REPORT

Master A, 10-year-old male child with uneventful birth and developmental history without past and family history of neurological and psychiatric illness presented with an illness of 1-month duration, which started with fearfulness, suspiciousness, irritability, decreased sleep. Two weeks later he developed decreased activity level, refusing food, remaining in one position for long hours and decreased production of speech. On examination, catatonic features like the negativism, immobility, mutism, posturing, and rigidity were observed. He was hospitalized with a diagnosis of acute and transient psychotic disorder with catatonic features as per the International Classification of Diseases-10th Edition criteria.[6] Investigations including complete hemogram, serum electrolytes, electro-encephalography and computed tomography of the brain were within the normal limits. On Bush-Francis Catatonia Rating Scale[7] he had a score of 24. He was started on injection lorazepam 4 mg twice a day with tablet olanzapine 7.5 mg for initial 6 days. He improved minimally with decrease in the catatonia score to 22. Injection lorazepam continued for next 3 days. However, no further improvement was noticed. So after taking informed consent of guardians ECT was started. Injection lorazepam was stopped. He was given five bilateral ECTs (Pulse width: 1 ms, duration: 0.7 s, frequency: 50 HZ, Current: 500-mA, energy: 3J) on alternative days. Motor seizure duration ranged from 30 to 45 s. His catatonic symptoms improved significantly with the ECT. The mini-mental status examination for children score varied between 24 and 27 during the course of ECT. No adverse effects of ECT were reported. Following resolution of catatonic symptoms ECT was stopped, and he was discharged from the hospital with the advice to continue tablet olanzapine 5 mg/day. After 1 month of follow-up, he was completely asymptomatic and his mini mental status examination for children score was 30.

DISCUSSION

Several studies[89] have indicated that lack of knowledge and experience with the use of ECT among child and adolescent psychiatrists is an obstacle to its appropriate use. Some mental health professionals may regard ECT as a controversial or unethical treatment. Concerns have been raised that ECT may interfere with the brain's growth and maturation and inhibit normal development in children and adolescents. But researchers[10] have suggested that psychiatric illnesses itself can be detrimental if left untreated by leaving biochemical alterations, gross pathological microscopic scars, and changes in neuronal connections. Another concern is the possibility of prolonged seizure in children and adolescents. Seizure thresholds are lower in childhood than in adults. The use of adult-level energies may elicit prolonged seizures, but such events may be minimized by using the lowest available energies; monitoring of electroencephalographic seizure duration and quality; and interrupting a prolonged seizure by effective doses of diazepam. We used the bilateral fronto-temporal and brief pulse ECT. As bilateral ECT is more effective than the unilateral ECT and brief pulse stimulation has fewer side effects as compared with the sine wave stimulation. The lack of severe adverse effects both in previously reported cases and in our patient suggests that ECT is safe to use in children and adolescents. But efficacy and safety of ECT in children and adolescents is not confirmed by any large followup studies. Hence, prospective studies exploring the long-term consequences of ECT in children and adolescents are necessary. More education and training is needed so that psychiatrists are comfortable considering and utilizing ECT as a treatment when appropriate.