Emergency Department and Inpatient Clinical Pathway
for Somatic Symptom and Related Disorders
- Related Pathways
- Behavioral Health Discharge Disposition, Inpatient
- Key Points
- Somatic symptoms are real (not faked).
- SSRD is a diagnosis of inclusion based on history and physical exam, not a diagnosis of exclusion.
- SSRDs typically do not benefit from admission.
- Children with chronic medical or behavioral diseases may also experience somatic symptoms, and their management is part of a complete and holistic treatment plan.
- Children with SSRD are typically harmed by overmedicalization. However, patients may occasionally pursue alternative diagnoses while treating their somatic symptoms, known as the "walking two paths" philosophy.
- Effective communication improves patient/family experience.
- FLOC/RN Assessment
- Additional History and Physical
- History/Physical exam inconsistent with known chief complaint
- Symptoms out of proportion to exam
- Symptoms present after stressful physical/emotional event
- Symptoms improve/resolve during sleep
- Presenting symptoms are better explained by an alternative medical and/or behavioral diagnosis.
- If somatic symptom present, please refer to the SSRDs patient family education page.
Somatic Symptoms are Primary Driver for Visit
Emergency Department Management
- Medical Management
- Alternative diagnostic workup if, indicated
- Consider chart review with relevant providers
(subspecialty, primary care) - Avoid unnecessary testing
- Avoid adding new medications
- Behavioral Health Management
- Complete behavioral health screen
- Begin Conversation with Child/Caregiver About SSRD Diagnosis
- Consult social worker to provide additional resources
- Psychiatry Consultation, as indicated
Admission Considerations
- Most children with SSRD do not benefit from admission. However, there are several specific indications for which children may benefit from a short and focused inpatient stay, such as:
- Diagnostic uncertainty
- Severe symptoms impairing function
(i.e., ADLS, mobility, school participation) - Co-morbid illness warranting admission
- Inappropriate or ineffective use of polypharmacy benefitting from inpatient demedicalization
- Medical Follow-up
- Follow-up with PCP within 1-2 weeks
of discharge - Consider PT/OT referral
- Provide SSRD PFEs and care bundles
- Other referral considerations
- Review medication management
- Follow-up with PCP within 1-2 weeks
- Behavioral Health Follow-up
- Provide resources/appointment
- Warm handoff to outpatient behavioral health provider as able
- Admit to General Pediatrics or relevant subspecialty if patient is already followed and subspecialty in agreement
- Review Goals of Admission
- Education and clarification of diagnosis
- Development of symptom management skills
- Education and clarification that treatment will focus on eventual return to function
- Care decisions driven by the inpatient team
- Medical Management
- Continue medically indicated workup while limiting non-indicated testing and consultations
- Obtain and review outside records as indicated
- Document diagnosis of SSRD in medical record
- Initial consultations with indicated subspecialists and PT/OT/SLP to address functional limitations, if applicable, within 24 hours
- Behavioral Health Management
- Consult BHIP, SW, and Integrative Health early
- Provide resources/appointment
- Warm handoff to outpatient behavioral health provider as able
- Communication
- Reinforce Goals for Admission with child and caregiver
- Plan for family meeting with SW if prolonged admission, multiple subspecialists involved, or unable to discharge due to child/family reluctance or severity of symptoms
Posted: May 2023
Revised: July 2023 Editors: Clinical Pathways Team
Revised: July 2023 Editors: Clinical Pathways Team
Evidence
- Pediatric Somatic Symptom and Related Disorders: Primary Care Provider Perspectives
- Standardizing Pediatric Somatic Symptom and Related Disorders Care: Clinical Pathway Reduces Health Care Cost and Use
- Health Care Use and Costs of Children, Adolescents, and Young Adults With Somatic Symptom and Related Disorders
- Executive Summary: Evaluation and Management of Children With Acute Mental Health or Behavioral Problems. Part II: Recognition of Clinically Challenging Mental Health Related Conditions Presenting With Medical or Uncertain Symptoms
- Effect of Timing of Psychiatry Consultation on Length of Pediatric Hospitalization and Hospital Charges
- Taking the Pain out of Somatization: Development and Implementation of a Hospital-Based Clinical Practice Guideline to Address Pediatric Somatic Symptom and Related Disorders
- Systematic Review of Misdiagnosis of conversion Symptoms and “Hysteria”
- Symptoms ‘Unexplained by Organic Disease’ in 1144 New Neurology Out-patients: How Often Does the Diagnosis Change at Follow-up?
- Clinical Progress Note: Management of Somatic Symptom and Related Disorders in Pediatric Inpatients
CHOP Programs
- Center for Amplified Musculoskeletal Pain Syndrome
- Acquired Autonomic Dysfunction Program
- Comfort Ability Workshop
- Integrative Health