Stuart, Segal, Keady (2014) — Psychiatric Adverse Effects of Pediatric Corticosteroid Use

Source

• Mayo Clinic Proceedings systematic review, 2014.
• URL: https://www.mayoclinicproceedings.org/article/S0025-6196(14)00063-9/fulltext

Why this paper is in the corpus

This is the most-cited pediatric synthesis on adverse psychological/psychiatric effects of corticosteroids (APSE) in children and adolescents. It is the reference review for two questions Levi's case raises directly: (1) how often do behavioral side effects appear in children on corticosteroid courses, and (2) when in the course do they appear — including whether they can appear after cessation.

Key findings

• APSE in children can include cognitive disorders, behavioral changes (mood swings, irritability, depression, anxiety, problems with behavioral control, aggression, attention), and frank psychiatric disease (mania, psychosis).
• APSE can occur at any point during treatment, including withdrawal.
• In adults, most psychiatric reactions occur early — many within the first week or two — and pediatric case reports are consistent with this trend (Tavassoli et al.).
• However, the review explicitly documents that pediatric psychiatric adverse events were sometimes delayed, emerging only after weeks of treatment or even after cessation.
• Several pediatric case studies report psychiatric reactions that began 1 to 11 days after corticosteroid administration was stopped, most often presenting as psychosis, with one case emphasizing combativeness and emotional lability.
• The review explicitly notes that dose-behavioral dyscontrol relationships cannot be calculated from existing pediatric data — the case literature is not large or comparable enough to establish dose-response curves.
• Treatment options in the case literature include benzodiazepines (lorazepam) and antipsychotics (risperidone) for severe presentations. In one case, lorazepam was added for a child inconsolable for 24 hours; in a teenager with psychosis after dexamethasone cessation, risperidone was added when lorazepam was inadequate.

Limitations relevant to Levi

• Heavily case-report-based; no prospective pediatric cohort estimates an absolute incidence rate of post-cessation behavioral worsening at the 2–6 week mark specifically.
• Most documented cases were of frank psychosis or severe behavioral dyscontrol, not the milder frustration/aggression presentation Jake and Miki describe.
• Almost no data specifically on a single 3-day high-dose IV pulse without taper, which is Levi's exact regimen.

Levi-relevant takeaways

• This is the strongest evidence base supporting that behavioral worsening after a pediatric steroid course is real and clinically recognized, even if the precise 2–6 week post-pulse timing is not directly characterized by a prospective cohort.
• It confirms the mechanism is not exotic — it is part of the well-known APSE spectrum and includes irritability and aggression, not only psychosis.
• It supports keeping pulse-related behavioral aftermath on the differential for Levi's current behavior change without inferring it must mean SWI rebound.