Improving the Quality of Care for Pediatric Patients with Somatic Symptoms and Related Disorders

The challenges of treating pediatric patients who present with somatic symptom complaints, or medically unexplained symptoms, are often accentuated by the lack of a standardized approach to care. Complicating things further is the length of time it typically takes to arrive at a diagnosis and provide adequate management, as well as inadequate provider-family communication and education about this complex condition.

In an interview with Consult QD, Emily Mudd, PhD, Clinical Psychologist in Cleveland Clinic Children’s Center for Pediatric Behavioral Health, discusses the Somatic Symptom and Related Disorders Care Path — a clinical care plan that aims to improve the quality of care and outcomes of pediatric patients with somatic symptoms through structured, evidence-based recommendations, and enhanced provider-family communication.

How frequently do pediatric patients present with somatic symptoms and which symptoms are most common?

Dr. Mudd: Somatic symptom and related disorders are reported at close to 10 percent in the general population, and up to 25 percent in children and adolescents, which makes it one of the most commonly reported disorders in the primary care setting and emergency department. The complex nature of somatic symptoms leads to a significant portion of patients being admitted to the inpatient floors. The symptoms these children present with typically fall into four different categories, including neurological manifestations such as conversion disorder and sleep disturbance; cardiac symptoms such as syncope; gastrointestinal symptoms such as chronic abdominal pain, nausea and rumination; and pain symptoms, such as amplified or chronic pain.

How do physicians typically arrive at a somatic symptom diagnosis?

Dr. Mudd: A child will likely be seen by a multidisciplinary team consisting of various professionals, including a primary care provider, pediatric subspecialist (depending on presenting symptoms), and psychologist. The evaluation typically includes a physical exam with medical tests as needed (possible lab work, imaging, etc.) and meeting with psychology to assess emotional, physical, and behavioral functioning.

What are some of the challenges associated with treating children who present with these symptoms?

Dr. Mudd: The families of children with somatic symptoms are typically very scared when they come to the hospital, and often request unnecessary medical interventions or diagnostic testing that is not indicated. Providers may lack the expertise to explain what is happening with the patient, which leads to an increase in difficulties in provider-patient/family communication. In addition, because patients with somatic symptoms often present with functional impairment, they may be admitted for extended periods of time or readmitted without a clear diagnosis and treatment plan.

What are the main goals of the Somatic Symptoms and Related Disorders Care Path?

Dr. Mudd: This care path is a set of evidence-based guidelines that aims to decrease unnecessary variation in patient care and promote safe and effective care for patients with somatic symptoms who have been admitted for inpatient care. The idea to integrate a clinical care pathway for patients with somatic symptoms stems from my earlier work at Connecticut Children’s Medical Center. Since my arrival at Cleveland Clinic in September 2018, I have been working with pediatric hospitalists Julie Cernanec, MD, Anika Kumar, MD, Michelle Marks, DO, and Chionye Ossai, MD, on completing the preparatory steps needed for integration of this new care path. We expect that it will be fully integrated and operational in on our inpatient pediatric floors by the end of 2019.

Can you briefly outline the practical aspects and components of this care path?

Dr. Mudd: The Somatic Symptoms and Related Disorders Care Path recommends psychological evaluation of the patient on the first day of admission, rather than a mid-admission pivot to psychology. Because there is a strong psychological component in patients who present with somatic symptoms, this approach can substantially shorten the length of hospital stay for patients, as well as provide answers for the family in diagnostic clarification. The care path will implement a functional approach on the first day of the admission as well, with goals that include completing the activities of daily living, demedicalization, and involving rehabilitation therapists if necessary (physical, occupational and speech therapy). Another focus area would be to track the hopeful trend of decreasing pain medications and unnecessary use of opioids.

Furthermore, this care path will emphasize the importance of provider-family communication by incorporating a family meeting with the primary attending physician, psychology, and any other subspecialty providers to review the diagnosis, etiology and treatment plan at discharge.

Which benefits do you expect that this care path will have for patients and providers?

Dr. Mudd: We expect that its implementation will result in improved patient care facilitated by a structured care path and consistency in admissions. Clinical pathways are traditionally also associated with reduced hospital stay, readmission rates and decreased costs for the health system and the patient. It will be exciting to see which of these practical benefits will be observed in our institution after implementation of this care path.

How many patients per year will be utilizing this care path?

Dr. Mudd: We expect that the pathway will serve around 40 to 50 pediatric patients per year here at Cleveland Clinic Children’s; the anticipated median age range of patients who will be utilizing this care path is between 12 and 17 years old.