Strategies to Facilitate Intravenous Access for Electroconvulsive Therapy Procedures in Pediatric and Neurodivergent Patients: A Case Series

Introduction

Electroconvulsive therapy (ECT) has been in use since 1938 for the treatment of severe and treatment-resistant psychopathology (Espinoza and Kellner, 2022). In young patients, ECT has been in use since the 1940s, with a 1947 article reporting on 98 children aged 12 or younger receiving ECT for “childhood schizophrenia” (many of whom would likely meet criteria for autism spectrum disorder under present nosology) demonstrating improvement in two-thirds of the patients (Bender, 1947). In present clinical use, ECT is used primarily for the treatment of depression (Luccarelli et al., 2021) and catatonia (Smith et al., 2024b), but there is emerging evidence for its utility in other disorders, including repetitive self-harm in patients with autism spectrum disorder (ASD) (Bloch and Ghaziuddin, 2016; Wachtel, 2019). Treatment of these disorders may sometimes require prolonged maintenance ECT courses (Smith et al., 2025; Wachtel et al., 2025), thereby requiring ongoing ECT and making it critical that the treatments be as tolerable as possible. Despite this evidence for clinical effectiveness, ECT is rarely used in pediatric patients (Luccarelli et al., 2020a, 2023), with legal restrictions on the use of ECT in many U.S. states (Livingston et al., 2018). Beyond legal restrictions, ECT administration in youth and among those with neurodevelopmental disorders (NDDs) can present with unique challenges. These include the unfamiliar environment of the ECT treatment area, which may provoke sensory overstimulation and anxiety, the requirement for intravenous (IV) access, and disruptions to a patient’s school and social activities caused by frequent treatments. Here we report a series of neurotypical and neurodivergent children and young adults for whom ECT was indicated but who had difficulty tolerating treatment. We present nonpharmacologic and pharmacologic strategies to enable ECT access in these individuals, particularly surrounding IV placement. This study involving the secondary use of medical records was reviewed by the Mass General Brigham Institutional Review Board and determined to be exempt.

Case 1: Oral Anxiolytic

In Case 1, the patient was a 16-year-old nonbinary individual with a history of major depressive disorder and generalized anxiety disorder with recurrent episodes of self-injurious behavior and repeated psychiatric hospitalizations over the past year. The patient had been treated with multiple antidepressants, mood stabilizers, and antipsychotic medications without significant change in symptom burden, and so the patient was referred for ECT consultation. At the time of initial consultation, the patient expressed substantial anxiety about ECT, particularly with IV placement. The patient was premedicated with quetiapine 50 mg the morning prior to ECT, as this agent does not have an adverse effect on seizure threshold. Once the patient arrived at the ECT suite, they were amenable to IV placement and ECT treatment. After the first three ECT sessions, they no longer required premedication with quetiapine. The patient ultimately achieved remission from depression with ECT and was able to return to school. They remained in remission at the 2-year follow-up.

Case 2: Physical Restraint

In Case 2, the patient was a 22-year-old male with ASD and intellectual disability presenting with depressive symptoms and increased aggression, which were refractory to multiple antidepressants, mood stabilizers, and antipsychotics. His multidisciplinary outpatient treatment team agreed with referral for ECT. The patient had sensory sensitivities and benefited from therapeutic holds and weighted blankets in his group home environment. Given his unique requirements for care, a multidisciplinary discussion with the outpatient treatment team, the patient, his parents, occupational therapy, hospital security, nursing, anesthesia, and ECT psychiatry resulted in the development of an individualized ECT care plan. This included travel to ECT with preferred group home staff and parents, security escort from the hospital entrance to provide an expedited and quiet route to ECT procedural area, a consistent treatment room in the quietest area of the treatment suite, use of preferred sensory strategies in treatment bay preprocedural, and physical restraint upon arrival to the ECT treatment room using a papoose board with only one arm exposed for IV access. The patient tolerated this protocol and was able to successfully tolerate a full course of acute ECT.

Case 3: Intramuscular Ketamine

Case 3 was a 14-year-old male with Trisomy 21 presenting with Down Syndrome Regressive Disorder with features of catatonia (Ghaziuddin et al., 2015; Smith et al., 2024a) that had been refractory to treatment with N-methyl D-aspartate (NMDA) agonists and lorazepam. The patient had a long-term fear of needles, which had made it impossible for blood draws or IV access to be obtained in several years. For this patient, anesthesia was induced using intramuscular (IM) ketamine followed by IV placement while the patient was partially anesthetized. IM ketamine administration is associated with medication-related risks, including hypersalivation, emergence of delirium, and prolonged recovery (Dave, 2019), and safety risks to patient and staff, as patients often require restraint and there is a high risk of needlestick if the patient becomes combative. However, this patient tolerated monitoring by pulse oximetry and being held by his mother while IM ketamine was administered at a dose of 3 mg/kg. An IV was successfully placed while the patient was anesthetized, and the typical IV anesthetic and muscle relaxant were given via that line. The IV was left in place and present when the patient awoke. Over the course of 4 months of ECT treatment, the patient gradually was sensitized to having the IV in place, and ultimately, he was able to tolerate IV placement without the requirement for IM ketamine induction. He has received maintenance ECT over several years without issue with IV placement.

Case 4: Inhalational Anesthetic

Case 4 was a 16-year-old male with profound ASD and intellectual disability presenting with catatonia refractory to high dose benzodiazepines. While generally hypoactive in his presentation, he was frequently aggressive with caregivers and negativistic, which made IV placement impossible when awake. IM ketamine induction as in Case 3 was attempted, but the patient would become combative with IM injection, as well as placing staff at risk of injury or needle stick. As a result, an inhalational anesthesia induction was performed using sevoflurane, with IV access obtained while the patient was anesthetized to allow for the administration of a muscle relaxant. Inhalational induction does pose some risks, most notably the risk of laryngospasm without IV access to treat it. Inhalational induction also requires patient cooperation or the forceful placement of a mask over the mouth and nose. While forceful placement can be achieved in small children, for this nearly adult-sized patient required that the team find a way to gain his cooperation (Dave, 2019). Occupational therapy worked with the patient to facilitate tolerance of the anesthesia mask, including the use of a preferred flavor of lip balm on the mask to avoid an unpleasant smell and taste from the volatile anesthetic. Using this technique, the patient was able to tolerate a full course of ECT with improvement in symptoms, and remains in maintenance treatment.

Case 5: Port Placement

Case 5 was a 27-year-old patient with DiGeorge syndrome, with associated intellectual disability and schizophrenia. The patient had psychotic symptoms that were substantially impairing his quality of life while treated with a variety of first- and second-generation antipsychotics. He was unable to tolerate clozapine due to agranulocytosis. He was referred for ECT for refractory schizophrenia. Even with ultrasound guidance, it was challenging to place an IV in this patient, resulting in numerous failed attempts during early treatments. This led to increased anxiety and patient avoidance of ECT. Given that the greatest challenge for this patient was definitive venous access and that there was expected need for numerous ECT treatments, including maintenance ECT, the patient was referred for implantation of a central venous access device. While a venous access port carries several risks, including infection, venous stenosis, and thrombosis (Machat et al., 2019), for this patient, these risks were far outweighed by the benefit. A right-sided Port-A-Cath was placed by interventional radiology, and this line was used for subsequent ECT treatments with no difficulty in obtaining access. The patient’s anxiety surrounding ECT decreased, and he was able to complete an acute course of ECT. He continues to receive maintenance ECT treatments.

Discussion

These cases highlight difficulties in tolerating ECT procedures experienced by neurodiverse children and young adults, particularly surrounding IV placement. In each case, individualized, multidisciplinary care adapted to the specific strengths and needs of each individual patient permitted effective treatment (Table 1).

Pediatric patients and those with NDDs face unique challenges in adapting to a health care system that is often not designed around their needs. (Malik-Soni et al., 2022). Factors including sensory sensitivities (Griffin et al., 2022), communication difficulties (Hickey et al., 2024), and challenging behaviors (Edelson, 2022) all present difficulties in health care settings. These can result in disparities in treatment access and worsened health outcomes in such patients (Bishop-Fitzpatrick and Kind, 2017). As a result, to advance health equity, it is critical to provide age- and developmentally appropriate strategies to access the full range of needed health procedures, including ECT. The repetitive nature of ECT, requiring multiple treatments as frequently as three times per week, provides unique challenges as patients must be able to tolerate multiple treatments rather than a single isolated procedure as may be required for a surgery. This makes it all the more critical to use strategies from the initiation of treatment that support individuals in accessing ECT in a developmentally appropriate manner.

The core principle underpinning all these cases was a careful alliance among the patient, caregivers, and the full treatment team to understand the patient’s unique needs within health care settings. This included a detailed review of previous interactions with health care to identify particular points of difficulty in the past and what strategies were or were not successful in managing these. Engagement of outpatient treaters who have worked with the patient longitudinally was also essential in optimizing home medications for the peri-ECT period. Additionally, collaboration with a designated Occupational Therapist Patient Navigator for Autism and Developmental Disabilities allowed for a detailed assessment of strategies for patient engagement and navigation of the ECT process. (Philpott-Robinson et al., 2024).

One common point of difficulty in these cases was the placement of an IV, which is necessary for the delivery of muscle relaxant to reduce the risk of physical injury during ECT (Luccarelli et al., 2020b). This has been recognized as a key point of difficulty in other procedures (Parry et al., 2021; Prakash et al., 2016), with a wide range of pharmacologic strategies utilized by anesthesia providers to facilitate procedural sedation (Kamat et al., 2018). The ECT procedure presents special difficulties in sedation, as agents that affect the seizure threshold, such as benzodiazepines and propofol, should be avoided to maximize seizure quality. As a result, we utilized oral neuroleptics (quetiapine), intramuscular ketamine (as reported in a single-center case series) (Srinivasan et al., 2025), and inhalational sevoflurane, as these agents have minimal effects on seizures. Other potential strategies could include dexmedetomidine or nitrous oxide (Sahyoun et al., 2023), as these agents likewise do not affect seizure threshold. Once IV access was obtained, the patients did not require modification of the typical ECT anesthesia protocol involving intravenous anesthetic and muscle relaxant.

Beyond pharmacologic strategies for assisting IV placement, Patient 5 benefited from avoiding IV placement entirely by placement of an implanted vascular access device. Such devices are in common use in pediatrics, for instance, for chemotherapy, with few side effects (Bawazir and Banoon, 2020). The device does require flushing every few months when not in active use (Lang et al., 2022), but for patients on maintenance ECT who are typically receiving treatments every few weeks, routine line care can be performed during the treatment itself. Moreover, there is a risk of infection or of line occlusion, which must be monitored for, particularly in the immediate postimplantation period (Machat et al., 2019). Given the need for multiple ECT treatments, and in this patient, ongoing maintenance ECT, this invasive procedure optimized the patient’s overall quality of life. No complications were observed in this patient from catheter placement or access in subsequent treatments.

Patient 2 benefited from planned physical restraint using a papoose board for treatments. This device had been utilized successfully for this patient in a prior treatment setting, and his outpatient team and parents felt strongly that it helped the patient remain regulated and not struggling against restraints. While the elimination of coercive physical restraints is a key goal of care (Dalton and Doupnik, 2024), and there is evidence of racial and other disparities in physical restraint usage (Luccarelli et al., 2024), in this case a planned brief restraint was consistent with his overall goals of care and was the least restrictive intervention allowing safe and tolerable access to ECT and appropriate anesthesia.

While individualized treatments were required for multiple of these patients initially, several of the patients became more comfortable and familiar with ECT treatments as they progressed and were able to be treated with more typical procedures. In these cases, consistency of treatment staff, environment, and procedures was critical to improving the overall experience of ECT, and by reducing trauma from early treatments with the strategies presented here, patients were able to successfully sensitize to the procedure. This is critical in maintaining comfort with maintenance ECT, which may be required in the long term in some cases.

Conclusions

Pediatric and neurodivergent patients have unique health care needs that require individualized treatment planning. In this series of cases, we describe strategies for facilitating ECT access in such patients, including pharmacologic and non-pharmacologic strategies for obtaining the repeated IV access required for ECT. Careful collaboration between patients, families, and interdisciplinary treatment teams is critical for advancing the care of pediatric and neurodivergent patients and is essential for advancing health equity in such populations.

Clinical Significance

Intravenous (IV) access is a critical step in the successful delivery of electroconvulsive therapy (ECT), but one that has particular challenges in pediatric and neurodivergent patients. This case series highlights clinical strategies to facilitate IV access in these populations for ECT and emphasizes the critical need for individualized treatment strategies.