Catatonic Features That May Be Mistaken for Worsening Autism Show Treatment-Associated Improvement: Implications for Later Regression

This publication is included in the Autistic Autism Scholarship Project. one author of this publication is identified as autistic in the project.

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Smith, J. R., Bonnee, M., Marler, S., Lim, S., Fuchs, C., Tamargo, R., Baldwin, I., Maley, C., VanHaverbeck, A., Hamilton, C., Adegoke, t., Xu, H., Liu, J., Williams, Z. J., Wilson, J. E., & Luccarelli, J. R. (2026). Catatonic Features That May Be Mistaken for Worsening Autism Show Treatment-Associated Improvement: Implications for Later Regression [Preprint]. openRxiv. https://doi.org/10.64898/2026.09.14.26363007

Publication date: 15 Sep 2026 Added to AutiHub: 17 Sep 2026 Type: Preprint Article language: English
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Authors

Publication authors
16
Publication authors identified as autistic
1 / 16 (6.2%)
  1. Joshua Ryan Smith
  2. Maria Bonnee
  3. Sarah Marler
  4. Seri Lim
  5. Catherine Fuchs
  6. Rafael Tamargo
  1. Isaac Baldwin
  2. Christopher Maley
  3. Ashley VanHaverbeck
  4. Courtney Hamilton
  5. timothy Adegoke
  6. Haozheng Xu
  1. Jinyuan Liu
  2. Zachary J. Williams *
  3. Jo Ellen Wilson
  4. James Ryan Luccarelli

Abstract

Catatonia in autistic individuals may resemble worsening autism yet represent a potentially treatable departure from baseline functioning. We compared item-level catatonic signs in autistic and non-autistic patients and evaluated treatment-associated change during electroconvulsive therapy (ECT). This single-center observational cohort included patients with catatonia who received ECT from May 2022 through April 2026. The 23-item Bush-Francis Catatonia Rating Scale (BFCRS) was assessed longitudinally. Pretreatment BFCRS data were available for 104 patients, including 41 autistic and 63 non-autistic patients, with 993 near-complete repeated assessments available. Pretreatment item presence was modeled using a three-level clinical-group variable with adjustment for age, biologic sex, and calendar year. Compared with non-autistic patients, patients with autism and intellectual disability had higher adjusted odds of eight activated, repetitive, or behaviorally dysregulated signs and lower odds of immobility/stupor. Among 96 patients with paired first and last eligible BFCRS assessments, multiple items improved in both cohorts. Generalized estimating equations demonstrated longitudinal declines in total BFCRS scores and multiple psychomotor-domain scores, with no clinical-group-by-time interaction surviving false-discovery rate correction in unrestricted or 30-, 60-, 90-, and 180-day models. Autism-specific Kanner analyses identified seven significant fixed-endpoint severity-item improvements after false-discovery rate correction, six of which were reproduced longitudinally. Catatonia in autism with intellectual disability was characterized by a phenotype that may resemble worsening autism during later regression, and many constituent signs demonstrated treatment-associated improvement during ECT.

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