Anti-NMDAR encephalitis in children: a psychiatric or neurological disorder? Impact of delayed diagnosis and treatment on cognitive recovery – a narrative review (2020–2026)

Abstract

Objective: This review synthesises the literature on paediatric anti-NMDAR encephalitis, focusing on the overlap between psychiatric and neurological symptoms and the impact of delayed diagnosis and treatment on cognitive recovery. Methods: A narrative review (2020 – April 2026) of the PubMed and Google Scholar databases was conducted, focusing on paediatric populations, treatment timing, and cognitive outcomes. Main results: In paediatric cohorts, psychiatric symptoms appear at disease onset in 80% of cases, though purely psychiatric presentations are rare. Because the disease mimics primary psychosis, 40% of patients are initially admitted to psychiatric wards, resulting in significant delays. Misdiagnosis poses a risk of life-threatening neuroleptic malignant syndrome in 12% of patients receiving antipsychotic medication. Initiation of immunotherapy within four weeks is a major modifiable factor associated with successful functional recovery (modified Rankin Scale, mRS 0–2). Delays exceeding 30 days are linked to a higher risk of persistent cognitive impairments, including memory and executive dysfunction, although prognosis is inherently multifactorial and influenced by disease severity and age. Long-term trajectories show complete remission in 73% of patients, isolated deficits in 18%, and multidomain impairment in 9%. Onset before the age of six is a critical vulnerability; 35% of these children remain dependent on social and family support a decade post-diagnosis. Conclusion: Paediatric anti-NMDAR encephalitis blurs the boundaries between neurology and psychiatry. Clinicians should actively identify neurological “red flags” to prevent misdiagnosis. Prompt multidisciplinary care and initiation of immunotherapy within four weeks help minimise cognitive deficits, prevent long-term dependency, and support restoration of the child’s normal neurodevelopmental trajectory, although final outcomes depend on clinical, radiological, and demographic factors.