Developing a Clinical Pathway for Somatic Symptom and Related Disorders in Pediatric Hospital Settings

An interdisciplinary intervention for children with complex health complaints; a feasibility study of selection criteria

Background

There is a need for re-designing the health service for children suffering from complex and compound health complaints. Based on a previous register study, we have developed criteria to select patients with complex health complaints eligible for an Intervention with an interdisciplinary professional team. The team consists of a pediatrician, a psychologist and a physiotherapist.

Method

To identify children with complex health complaints who would benefit from this intervention, we have selected a group of patients by using a set of criteria consisting of the following criteria: multi-referred young school age children referred to both mental health service and pediatric service. This study focuses on the feasibility of these criteria by measuring participation and compliance and by gathering feedback from the team members in the interdisciplinary team.

Results

Among 677 children aged 6-12 years referred to a regional hospital, we found 32 (5%) children eligible for the interdisciplinary Intervention according to the applied criteria. Only 6% of the invited parents declined to participate in the intervention. According to the interdisciplinary team, the intervention was found suitable for 88% of the children.

Conclusion

The suggested criteria seemed feasible, in terms of identifying eligible patients for this interdisciplinary Intervention for children with complex health complaints.

Clinical Trial Registration

Retrospectively registered on www.clinicaltrials.gov, ID NCT04652154, on the 3rd of December 2020.

Clinical Impact of Systematic Assessment and Psychoeducation in Specialized Treatment of Adolescents with Severe Functional Somatic Disorders: Results from the AHEAD Study

Functional somatic disorders (FSD), characterized by persistent and disabling physical symptoms, are common in adolescents. Diagnostic uncertainty and insufficient illness explanations are proposed perpetuating factors that may constitute barriers for treatment engagement. This study describes the impact of manualized assessment and psychoeducation on diagnostic certainty and various clinical outcomes in adolescents with multi-system FSD. Ninety-one adolescents (15-19 years) received systematic assessment (4 h) and a subsequent psychiatric consultation (1.5 h). Clinical characteristics included self-reported physical health, symptom severity, illness perception, illness-related behavior, and psychological flexibility assessed before and approximately two months after assessment, prior to specialized treatment. Data were analyzed using t-tests. Immediately following assessment, 71 (80.7%) adolescents out of 88 reported a higher diagnostic certainty and 74 (84.1%) reported that attending assessment gave them positive expectations for future treatment. A clinically relevant improvement of physical health was not observed at two months but considerable reductions were seen in symptom severity, illness worry, negative illness perceptions, illness-related limiting behavior, and psychological inflexibility. The results emphasize that systematic assessment and psychoeducation are important in their own right in the specialized treatment of adolescents with severe FSD.

Clinical and psychopathological profiles of children with somatic symptom disorders in a pediatric emergency unit: an observational study before and during the SARS-CoV-2 pandemic

Somatic symptom disorders (SSDs) are a group of clinical conditions characterized by heterogeneous physical symptoms, not directly supported by a demonstrable organic process. Despite representing a growing problem in the pediatric age, the literature lacks studies assessing the psychopathological and clinical features of subjects with SSD, particularly during the SARS-CoV-2 pandemic. This is a retrospective, observational study, involving two historical cohorts of children admitted to a tertiary referral Italian hospital over the 2 years preceding and following the start of the SARS-CoV-2 pandemic. Demographic, clinical, socio-economical, and psychological variables were investigated. Standardized tests for the developmental age were administered to assess psychopathological variables. Overall rates and trends of accesses for SSD, as compared to the total accesses for any cause at the Pediatric Emergency Room during the same periods, were reported as well. Fifty-one (pre-pandemic, 29; pandemic, 22) children with SSD were enrolled (age, 11.4 ± 2.4 years, F = 66.7%). Subjects in the pandemic historical cohort reported more frequently fever (p < 0.001), headache (p = 0.032), and asthenia (p < 0.001), as well as more chronic conditions in personal and family history, and fewer previous hospital accesses, as compared to the pre-pandemic cohort. Depressed mood and anxious traits were documented in both samples. None of them had an ongoing or a previously reported SARS-CoV-2 infection. During the pandemic, a clinical psychologist was more frequently consulted before the hospital discharge to mental health services, to support the diagnosis.  Conclusion: This study showed the significant burden of SSD in children, highlighting the need to implement pediatricians' education to optimize the management of these patients. Children with SSD who accessed during the SARS-CoV-2 pandemic presented specific clinical features. Future studies, conducted on longitudinal and controlled samples, are indicated to further investigate children with these conditions. What is Known:    • Somatic symptoms disorders (SSDs) are frequent in the pediatric age, especially in early adolescence.    • Evidence remains scarce on the impact of the SARS-CoV-2 pandemic on SSDs in children. What is New:    • Children with SSD who accessed during the SARS-CoV-2 pandemic presented specific clinical features.    • The implementation of pediatricians' education and a multidisciplinary approach are needed to optimize the management of SSDs.

Case report: New insights into persistent chronic pelvic pain syndrome with comorbid somatic symptom disorder

Chronic pelvic pain syndrome (CPPS) is generally defined as pain in the pelvic area that persisted for 3-6 months or longer. The pain can be constant or episodic and functionally disabling. Any dysfunction of the central nervous system can lead to central sensitization, which enhances and maintains pain as well as other symptoms that are mediated by the central nervous system. It occurs in subgroups of nearly every chronic pain condition and is characterized by multifocal pain and co-occurring somatic symptoms. Somatic symptom disorder (SSD) is defined as a condition in which having one or more somatic symptoms, such as excessive worries, pressure, and catastrophic events. These symptoms can be very disruptive to a patient's life and can cause significant distress. SSD cases with severe symptoms frequently undergo repeated medical investigations and the symptoms often lead patients to seek emergency medical treatment and consult with specialists repeatedly, which is a source of frustration for patients and clinicians. Here we report a case that Asian female with persistent CPPS with comorbid SSD, who got in trouble for up to 8 years. This case reminds clinicians to pay excessive attention to the diagnosis of CPPS with comorbid SSD after recovery from acute COVID-19, with hope of raising awareness in the identification of SSD and present new insight into appropriate treatment for each woman who suffers from it.

The Biopsychosocial Model in Paediatric Clinical Practice; - a Multidisciplinary Approach to Somatic Symptom Disorders

AIM

The paper aims to show how the biopsychosocial (BPS) model can be applied as a clinical method and guide the assessment and treatment of children and adolescents with Somatic Symptom Disorders (SSD).

METHODS

Based on relevant literature and our clinical work with children and adolescents with SSD we have developed a method to ensure a structured, interdisciplinary examination of biological, psychological and social factors, operationalising the BPS model into a clinical method.

RESULTS

The BPS model renders assessment and treatment of complex conditions as a basis for evaluating phenomena not confined by diagnostic tools, but still includes all information from these tools. It requires an interdisciplinary approach, giving individual patient and caregivers a central position. A thorough medical examination is required as a starting point for assessments. Good results rest upon a shared understanding between patient, caregivers and professionals.

CONCLUSIONS

"Biopsychosocial" is often claimed as a basis for clinical work with complex cases, medical, functional, and psychiatric, but scarcely with a corresponding BPS method or practice. The BPS method should guide further development of holistic, multidisciplinary health care on all levels, in order to assess and help children and adolescents with SSD.

Efficacy of physiotherapy treatments in children and adolescents with somatic symptom disorder and other related disorders: systematic review of the literature

According to the latest version of the Diagnostic and Statistical Manual of Mental Disorders, somatic symptom and related disorders (SSRDs) are defined as psychopathological manifestations characterized by physical signs not attributable to organic pathology. Their incidence has grown dramatically over the past few decades, and treatment is challenging. Besides other interventions on the child and the family, physiotherapy is considered an integral part of the treatment, although there is no evidence for its efficacy.

The study aimed to review the available proof on the effectiveness of physiotherapy in children and adolescents with SSRDs. A systematic literature search was conducted on MEDLINE/PubMed, CINAHL, Cochrane Library, PsycINFO, and PEDro, including 1999 to 2021. The methodological quality of the publications was assessed by applying the guidelines proposed by the Equator network, according to the different study designs. The scientific bibliography on the subject was minimal and had poor methodological quality. The choice of outcome indicators and the scales to measure them varied from study to study and were not standardized, making comparison and meta-analysis challenging.

Conclusion: According to the available evidence, it is impossible to answer the review question regarding the effectiveness of physiotherapy in children and adolescents with SSRDs. It is necessary to improve the methodological quality of the studies. Definition of standard rehabilitation treatments, identification of appropriate result indicators, and adoption of standardized evaluation scales are needed.

When feelings hurt: Learning how to talk with families about the role of emotions in physical symptoms

Emotions are at the core of all human experiences, but talking about emotions is challenging, particularly in the context of medical encounters focused on somatic symptoms. Transparent, normalizing, and validating communication about the mind-body connection opens the door for respectful, open dialogue between the family and members of the care team, acknowledging the lived experience that is brought to the table in understanding the problem and co-creating a solution.

Pediatric Avoidant-Restrictive Food Intake Disorder and gastrointestinal-related Somatic Symptom Disorders: Overlap in clinical presentation

Certain presentations of Avoidant/Restrictive Food Intake Disorder (ARFID) and Somatic Symptom and Related Disorders (SSRDs) have conceptual overlap, namely, distress and impairment related to a physical symptom. This study compared characteristics of pediatric patients diagnosed with ARFID to those with gastrointestinal (GI)-related SSRD. A 5-year retrospective chart review at a tertiary care pediatric hospital comparing assessment data of patients with a diagnosis of ARFID (n = 62; 69% girls, M_age = 14.08 years) or a GI-related SSRD (n = 37; 68% girls, M_age = 14.25 years). Patients diagnosed with ARFID had a significantly lower percentage of median BMI than those with GI-related SSRD. Patients diagnosed with ARFID were most often assessed in the Eating Disorders Program, whereas patients diagnosed with an SSRD were most often assessed by Consultation-Liaison Psychiatry. Groups did not differ on demographics, psychiatric diagnoses, illness duration, or pre-assessment services/medications. GI symptoms were common across groups. Patients diagnosed with an SSRD had more co-occurring medical diagnoses. A subset (16%) of patients reported symptoms consistent with both diagnoses. Overlap is observed in the clinical presentation of pediatric patients diagnosed with ARFID or GI-related SSRD. Some group differences emerged, including anthropometric measurements and co-occurring medical conditions. Findings may inform diagnostic classification and treatment approach.

Pediatric Somatic Symptom and Related Disorders: Parent Acceptance Influences Recovery

OBJECTIVES

To assess how clinicians discuss the diagnosis of somatic symptom and related disorders (SSRDs) in patients admitted to a children's hospital and explore the effect of parent and patient acceptance of the diagnosis on recovery.

STUDY DESIGN

In this cross-sectional study, we reviewed the electronic medical records of pediatric admissions diagnosed with SSRD over 18 months. All diagnostic discussions with patients and families were analysed to identify concepts used by clinicians within these discussions and the extent of parent and patient acceptance of the diagnosis. Recovery status up to 12 months after diagnosis was also identified. Acceptance and recovery were categorized as "full," "partial," or "none."

RESULTS

Ninety-five of 123 (77.2%) patients (median age 14.3 years, range 7.3-18.3) had at least 1 diagnostic discussion recorded. Clinical explanations within the diagnostic discussion spanned a variety of concepts, with the most common being a description of somatization (62%). Full parent acceptance of the diagnosis of SSRD was more likely when discussions involved two parents (P = .002). Full acceptance of the diagnosis by at least 1 parent was associated with complete functional recovery in their children (OR 8.94, 95% CI 2.24, 35.9, P = .002). In contrast, there was no significant association between full acceptance by patients and their recovery.

CONCLUSION

The influence of parent acceptance of the diagnosis of SSRD reinforces the importance of therapeutic engagement with families, as well as with children and adolescents.

Training Needs Assessment Survey in Pediatric Consultation-Liaison Psychiatry

OBJECTIVE

Despite growing recognition of how curriculum modules can benefit child and adolescent psychiatry (CAP) training, there are few standardized teaching resources for pediatric consultation-liaison psychiatry (PCLP). A Special Interest Group (SIG) of the American Academy of Child and Adolescent Psychiatry Physically Ill Child Committee (PICC) conducted a needs assessment to establish interest in, and availability of, a library of online, self-paced learning modules specific to PCLP.

METHOD

An email needs assessment survey was distributed to the PICC listserv in the fall of 2019 with four core areas of inquiry: (1) clinical service description, (2) teaching barriers, (3) interest in curriculum resources, and (4) interest in evaluation resources.

RESULTS

Respondents were representative of typical academic PCLP programs. The response rate was 28% (n = 39). Programs endorsed barriers to teaching including high service obligations and limited protected teaching time. All respondents indicated that they would utilize high-quality, online learning modules. Psychiatric complications of medical illness, catatonia, and delirium were identified as priority topics in the care of pediatric patients with comorbid medical conditions.

CONCLUSIONS

There are currently no published educational studies regarding the training needs for PCLP programs, even among tertiary care academic facilities. This training needs assessment is the first step in establishing a national PCLP training curriculum. New paradigms to develop standardized curriculum resources for PCLP are needed.

Weekend Admissions for Somatic Symptom and Related Disorders and Length of Stay

OBJECTIVES

To evaluate whether admission on weekends affects the length of stay (LOS) for patients hospitalized with somatic symptom and related disorders (SSRDs).

METHODS

Data from 2012-2018 was obtained for all patients aged 4 to 21 years (N = 5459) with a primary discharge diagnosis of SSRDs from 52 tertiary care pediatric hospitals in the United States. We obtained patient demographics, admission date and/or time, LOS, procedure count, and comorbid conditions. We defined a weekend as 3 pm Friday to 3 pm Sunday. The Wilcoxon rank test was used for unadjusted analysis. Multiple logistic regression was used to estimate the odds of having LOS >1 day, >2 days, >3 days, and >4 days in weekend versus weekday groups.

RESULTS

Weekend admission significantly correlated with increased LOS (P < .001). Compared with weekdays, a weekend admission was associated with increased odds of having LOS >1, >2, and >3 days. This remained statistically significant while adjusting for the number of chronic conditions, procedures, and individuals with Black or Hispanic ethnicity compared with White ethnicity. LOS was not associated with sex or age of the patients.

CONCLUSIONS

Patients with SSRDs admitted on the weekend have an increased LOS compared with those admitted on a weekday. This may be due to a decrease in multidisciplinary care available during weekends. In future studies, researchers should aim to better understand the specific factors that contribute to this disparity and test interventions that may close the gap in care, including expanding to 7-day services, increasing mental health resources, and working to decrease the need for inpatient admissions.

Automated clinical pathway standardization using SNOMED CT- based semantic relatedness

The increasing number of patients and heavy workload drive health care institutions to search for efficient and cost-effective methods to deliver optimal care. Clinical pathways are promising care plans that proved to be efficient in reducing costs and optimizing resource usage. However, most clinical pathways are circulated in paper-based formats. Clinical pathway computerization is an emerging research field that aims to integrate clinical pathways with health information systems. A key process in clinical pathway computerization is the standardization of clinical pathway terminology to comply with digital terminology systems. Since clinical pathways include sensitive medical terms, clinical pathway standardization is performed manually and is difficult to automate using machines. The objective of this research is to introduce automation to clinical pathway standardization. The proposed approach utilizes a semantic score-based algorithm that automates the search for SNOMED CT terms. The algorithm was implemented in a software system with a graphical user interface component that physicians can use to standardize clinical pathways by searching for and comparing relevant SNOMED CT retrieved automatically by the algorithm. The system has been tested and validated on SNOMED CT ontology. The experimental results show that the system reached a maximum search space reduction of 98.9% within any single iteration of the algorithm and an overall average of 71.3%. The system enables physicians to locate the proper terms precisely, quickly, and more efficiently. This is demonstrated using case studies, and the results show that human-guided automation is a promising methodology in the field of clinical pathway standardization and computerization.

Pediatric somatization in the emergency department: assessing missed opportunities for early management

OBJECTIVE

Somatization is a common phenomenon that can severely complicate youths' functioning and health. The burden of somatization on pediatric acute care settings is currently unclear; better understanding it may address challenges clinicians experience in effectively caring for somatizing patients. In this study, we estimate the prevalence of somatization in a pediatric emergency department (ED).

METHODS

We conducted a retrospective cross-sectional study of visits for non-critical, non-mental health-related concerns (n = 150) to a quaternary-level pediatric ED between July 2016 and August 2017. Demographic and clinical visit details were collected through chart review and used by two reviewing clinicians to classify whether each visit had a "probable," "unclear" (possible), or "unlikely" somatizing component.

RESULTS

Approximately 3.33% (n = 5) of youth displayed probable somatization, and an additional 13.33% (n = 20) possibly experienced a somatizing component but require additional psychosocial and visit documentation to be certain. Longer symptom duration and multiple negative diagnostic tests were associated with a higher likelihood of either probable or possible somatization.

CONCLUSIONS

A considerable proportion of non-mental health-related visits may involve a somatizing component, indicating the burden of mental health concerns on the ED may be underestimated. A higher index of suspicion for the possibility of somatization may support clinicians in managing somatizing patients.

Psychogenic non-epileptic seizures in children

Psychogenic Non-Epileptic Seizures (PNES) are a relatively common condition in children. While their clinical presentation resembles epileptic seizures, the underlying cause for PNES involves a multitude of bio-psychosocial factors. Patients may be misdiagnosed with epilepsy and subjected to unnecessary treatments, often delaying the diagnosis for years. A strong understanding of its symptomatology is essential for diagnosis of PNES. Successful management depends on effective teamwork that involves the neurologist as well as mental health professionals. This paper reviews the various aspects of PNES in children with emphasis on the clinical presentation, diagnosis as well as the underlying psychological basis and treatment.

Somatic symptom and related disorders in a tertiary paediatric hospital: prevalence, reach and complexity

Specialist paediatric services manage a variety of presentations of functional somatic symptoms. We aimed to describe the presentation and management of children and adolescents with somatic symptom and related disorders (SSRDs) requiring admission to a tertiary children's hospital with the objective of informing the development of a local clinical pathway. Patients admitted to any hospital department from May 2016 to November 2017 were identified through an electronic medical record (EMR)-linked diagnosis of SSRD. Each record was reviewed for demographic details and admission histories. The frequency of interspecialty consultations and multidisciplinary team (MDT) family meetings were recorded. One hundred twenty-three patients with SSRD were admitted on 203 occasions to 17 different departments. The median (range) age was 14.3 (7.3-18.3) years. Interspecialty consultations occurred in 84.6% of patients, and MDT family meetings occurred in 18.9% patients. SSRD was diagnosed as an inpatient in 79.9% patients, yet only 40.7% of patients, including those with multiple admissions, had SSRD recorded as a discharge diagnosis.Conclusion: Despite high rates of consultation with hospital teams, the frequency of MDT family meetings was low, and less than half the patients had SSRD documented at discharge. This affirms the value of developing a local clinical pathway. What is Known • Functional somatic symptoms are commonly seen in children and adolescents. • Few studies have explored the reach of functional somatic symptoms across a tertiary paediatric hospital; the majority of inpatient studies have focused on a limited set of disorders or cases referred to psychiatry departments. What is New • Symptoms that spanned multiple body systems were the most common presentation of SSRDs in admitted children and adolescents. • Somatic symptom disorders are less likely to be recorded as a discharge diagnosis compared with functional neurological symptom disorder.

How to recognize and manage psychosomatic pain in the pediatric emergency department

Aim

Children and adolescents affected by somatization and somatic symptom disorder commonly refer to emergency services. Due to the absence of specific guidelines for the emergency setting and to a possible lack of knowledge, these patients are at risk of being unrecognized and mismanaged. This study aims at proposing a clinical practice to approach and manage these patients and their families in the emergency setting.

Methods

This manuscript derived from the work of a research group of italian pediatric emergency physicians and anesthesiologists, with an expertise in pain management, members of the PIPER group. The research group reviewed the literature about psychosomatic pain and somatic symptom disorder and developed a clinical practice specific for the pediatric emergency setting.

Results

The manuscript provides information about the main clinical features shared by patients with psychosomatic pain and about current diagnostic criteria and appropriate management in the emergency setting. Furthermore, it highlights the possible pitfalls in which the emergency physician may run into dealing with these patients.

Conclusion

This clinical practice should be seen as a starting point toward a better understanding of patients with psychosomatic pain and a standardization of care in the pediatric emergency setting.

Suicide and suicidality in somatic symptom and related disorders: A systematic review

OBJECTIVE

We sought to determine the frequency of and risk factors for suicide outcomes in somatic symptom and related disorders and whether any risk was independent of co-occurring mental disorders.

METHODS

We conducted a systematic review of studies on suicide death, suicide attempts, and suicidal ideation in those with somatic symptom disorders published prior to September 22, 2020 and indexed in PubMED, MEDLINE, PsycARTICLES, PsycINFO, EMBASE, or SCOPUS according to PRISMA guidelines.

RESULTS

Our search yielded 33 articles with significant heterogeneity in study design, sample selection, and assessment for suicide or risk factors. While suicide deaths have not been adequately studied, somatic symptom and related disorders are associated with increased risk for suicidal ideation and suicide attempts, with estimates ranging from 24 to 34% of participants who endorsed current active suicidal ideation and 13-67% of participants who endorsed a prior suicide attempt. The risk appeared independent of co-occurring mental disorders. Identified risk factors for suicide attempts in samples with somatic symptom and related disorders include scores on measures of anger, alexithymia, alcohol use, past hospitalizations, dissociation, and emotional abuse.

CONCLUSION

Although the literature is sparse, there exists evidence for an association, even independent of other mental disorders, between somatic symptom and related disorders and suicide outcomes. Practice guidelines for the management of these disorders should incorporate recommendations for the assessment and management of suicide risk. Future study is necessary to more fully elucidate potential unique risk factors for those suffering from these complex disorders.

Interdisciplinary Approaches Suggested for Children With Multiple Hospital Referrals Presenting With Non-specific Conditions

Aims: To describe the care patterns of patients with repeated referrals to both mental and somatic specialist healthcare, and to study their diagnostic processes. Methods: In a previous register study patients aged 6-12 years referred to Haukeland University Hospital from 2013 to 2015, we found 922 children with at least three referrals including both somatic and mental health services. Of these, more than one in four (250) were randomly selected and observed from their first hospital episode ever and further after inclusion followed during their next three referrals or until July 2017. Data on referral patterns and diagnostics were collected from patient hospital records. Results: Mean number of referrals was 6.5 prior to inclusion and 4.2 in the follow-up period. At the end of the study period 15% of patients still had a non-specific diagnosis. During the follow-up period, more than half of the children were again referred across the border between somatic and mental healthcare. Conclusion: Very complex care patterns were found for these patients, who were repeatedly being referred and "crossing over" between mental and somatic healthcare. This indicates a need for more interdisciplinary-based approaches both within specialist care and between different care levels to broaden the perspective and achieve shorter time lag before reaching a diagnostic conclusion. Trial Registration: Data was obtained from Haukeland university hospital the patient registry system No. 2017/12470. Start of registration was April 1th 2017 and patients included was from 2013 to 15.

Ontological framework for standardizing and digitizing clinical pathways in healthcare information systems

BACKGROUND AND OBJECTIVE

Most healthcare institutions are reorganizing their healthcare delivery systems based on Clinical Pathways (CPs). CPs are novel medical management plans to standardize medical activities, reduce cost, optimize resource usage, and improve the quality of service. However, most CPs are still paper-based and not fully integrated with Health Information Systems (HIS). More CP computerization research is therefore needed to fully benefit from CP's practical potentials. A major contribution of this research is the vision that CP systems deserve to be placed at the centre of HIS, because within CPs lies the very heart of medical planning, treatment and impressions, including healthcare quality and cost factors.

METHODS

An important contribution to the realization of this vision is to fully standardize and digitize CPs so that they become machine-readable and smoothly linkable across various HIS. To achieve this goal, this research proposes a framework for (i) CP knowledge representation and sharing using ontologies, (ii) CP standardization based on SNOMED CT and HL7, and (iii) CP digitization based on a novel coding system to encode CP data. To show the feasibility of the proposed framework we developed a prototype clinical pathway management system (CPMS) based on CPs currently in use at hospitals.

RESULTS

The results show that CPs can be fully standardized and digitized using SNOMED CT terms and codes, and the CPMS can work as an independent system, performing novel CP-related functions, including useful data analytics. CPs can be compared easily for auditing and quality management. Furthermore, the CPMS was smoothly linked to a hospital EMR and CP data were captured in EMR without any loss.

CONCLUSION

The proposed framework is promising and contributes toward solving major challenges related to CP standardization, digitization, and inclusion in today's modern computerized hospitals.

Measuring functional recovery in somatic symptom and related disorders: a scoping review

OBJECTIVE

Somatic symptom and related disorders (SSRDs) are prevalent, heterogenous conditions that have the potential to profoundly affect normative function in children and adolescents. Yet there is little understanding of pathways to recovery. This study aimed to systematically scope how functional recovery has been measured in children and adolescents with SSRD .

DESIGN

Scoping review of primary studies.

METHOD

Medline (Ovid) and PsychInfo were systematically searched for publications from January 1998 to April 2019. Primary studies in English that reported functional outcomes of children and adolescents with SSRD were included. Case reports and population studies were excluded. Within the tools and clinician notes, the core domains of functional outcome were identified.

RESULTS

Sixteen studies were identified that used 11 different functional outcome tools. The domains assessed within these functional outcome tools, together with the domains noted by clinicians, included physical and mental health symptoms, as well as school attendance and academic outcomes, recreational participation, impact on family and service utilisation. There was no evidence of a preferred outcome measure as only two of the tools were used in more than one study.

CONCLUSIONS

The variability of tools and domains used to measure functional recovery in children and adolescents with SSRD suggests lack of conceptual agreement about what constitutes functional recovery. Continued focus on symptom measurement or mental health comorbidities risks limiting research to single types of disorder (eg, functional neurological disability) or interventions, which threatens a much needed wider research agenda around appropriate treatment, including of complex and persistent disorders.

Standardizing Pediatric Somatic Symptom and Related Disorders Care: Clinical Pathway Reduces Health Care Cost and Use

BACKGROUND

Pediatric somatic symptom and related disorders (SSRDs) are common with high health care costs and use because of lack of standardized, evidence-based practice. Our hospital implemented a clinical pathway (CP) for SSRD evaluation and management. Our study objective was to evaluate health care cost and use associated with the organization's SSRD CP in the emergency department (ED) and inpatient settings hypothesizing lower cost and use in the CP group relative to controls.

METHODS

We conducted a retrospective analysis of costs and use before and after implementation of the SSRD CP. Data were collected from the hospital's electronic health record and the Pediatric Health Information System database. Participants included pediatric patients on the CP ("P" group) and control groups with an SSRD diagnosis and mental health consultation either the year before the CP ("C" group) or during the CP study period ("T" group). Primary outcomes included costs, length of stay, diagnostic testing, imaging, subspecialty consultation, and readmission rates.

RESULTS

The ED P group had more lower-cost imaging, whereas the inpatient T group greater higher-cost imaging than other groups. The inpatient P group had significantly shorter length of stay, fewer subspecialty consults, and lower costs. There were no significant group differences in readmission rates. The CP reduced median total costs per patient encounter by $51 433 for the inpatient group and $6075 for the ED group.

CONCLUSIONS

The CP group showed significant reductions in health care cost and use after implementation of a CP for SSRD care. In future work, researchers should explore patient and practitioner experience with the SSRD CP and long-term outcomes.

Feasibility of group-based acceptance and commitment therapy for adolescents (AHEAD) with multiple functional somatic syndromes: a pilot study

BACKGROUND

Recurrent and impairing functional somatic syndromes (FSS) are common in adolescents. Despite a high need for care, empirically supported treatments are lacking for youth. The aim of this uncontrolled pilot study was to assess feasibility and treatment potential of a new intervention with group-based Acceptance and Commitment Therapy (ACT) in a generic treatment approach for adolescents with multiple FSS.

METHODS

Twenty-one patients received 'ACT for Health in Adolescents' (AHEAD) (30 h), specifically developed for adolescents (aged 15-19 years) with moderate to severe FSS. Close relatives attended an information meeting to facilitate support of the patients throughout treatment. Treatment satisfaction was evaluated by means of self-report and relatives' impressions. Self-reported physical health at 3 months follow-up (FU) after end of treatment was the primary outcome whereas secondary outcomes included symptom burden, limitation due to symptoms, illness worry, emotional distress and physical and emotional symptoms. Treatment targets were assessed by measures on illness behaviour, illness perception and psychological inflexibility.

RESULTS

Nineteen patients (90.5%) completed the treatment with a high overall attendance rate of 93%. All would recommend the treatment to a friend with similar problems. Close relatives rated it valuable to participate in an information meeting. Patients' physical health improved significantly from assessment to FU with a clinically relevant mean change of 8.9 points (95% CI [5.4; 12.4]; SRM 0.91 [0.26;1.57]). Improvement was also seen on all secondary outcome measures, from assessment to FU. Maladaptive illness behaviours and perceptions as well as psychological inflexibility showed a significant decline from assessment to FU.

CONCLUSION

AHEAD was feasible and potentially efficacious and warrants testing in a larger clinical trial.

TRIAL REGISTRATION

Clinical Trials gov NCT04464447 , registration date July 9th, 2020. Retrospectively registered.

Prevalence, Patterns, and Correlates of Pain in Medically Hospitalized Pediatric Patients With Somatic Symptom and Related Disorders

BACKGROUND

Somatic symptom and related disorders (SSRDs) and pain are highly comorbid in the pediatric population. Little is known about the prevalence of pain and factors that may predispose and perpetuate pain in hospitalized youth with SSRD.

OBJECTIVE

To describe the prevalence of pain and widespread pain symptoms in hospitalized youth with SSRD and describe differences between patients who endorsed limited (1-4 sites) versus widespread (5-8 sites) pain.

METHODS

Retrospective chart reviews were conducted of pediatric patients with SSRD seen over a 32-month period at a tertiary pediatric hospital and assessed by the psychiatry consultation service. During admission, patients completed the Childhood Somatization Inventory, which assessed pain and other physical symptoms. Descriptive statistics, one-way analysis of variances, Pearson's χ², stepwise linear regressions, and internal consistency analyses were used.

RESULTS

Of the 219 patients (aged 8-18 y), 97% reported pain symptoms, and of those reporting pain (n = 213), 48% reported widespread pain. Patients with widespread pain had greater rates of comorbid depression (P = 0.012), neglect (P = 0.016), family psychiatric history (P = 0.013), diagnostic tests/procedures (P = 0.012), and prescribed opioid use (P = 0.016), when other medical and demographic factors were considered. When compared dichotomously to youth with limited pain, there was no difference in prevalence of medical conditions; however, patients with widespread pain had higher rates of trauma and stressor-related disorders (P = 0.017), sexual abuse (P = 0.031), emotional abuse (P = 0.041), and prior child protective service involvement (P = 0.011).

CONCLUSIONS

Pain symptoms and widespread pain are common in medically hospitalized youth with SSRD, with unique psychiatric and psychosocial factors associated with widespread pain.

Somatization in acute care pediatrics: Respecting the mind-body connection

Somatic symptom disorder is a complex condition linking distress in the mind to physical distress in the body. However, in addition to the disorder itself, experienced clinicians know that children and youth frequently experience somatizing symptoms. With an increasing prevalence of anxiety in the pediatric population, symptoms attributable to process of "somatizing" are common, and early identification and rapport building to address the root causes of a child's distress are critical for a good outcome. In the acute care setting, clinicians are often reluctant to make the diagnosis of somatization. Part of the challenge is encouraging clinicians to see that somatization is not a "diagnosis of exclusion." We want to encourage clinicians to routinely consider risk factors for somatization in their histories, actively discuss the mind-body connection with patients and families, and include somatization in a carefully considered differential diagnosis. The more we can break down the siloing of physical from mental health, the better we will serve our patients.

Health Care Use and Costs of Children, Adolescents, and Young Adults With Somatic Symptom and Related Disorders

IMPORTANCE

Somatic symptom and related disorders are highly prevalent mental health disorders among young people. Presentation can be varied, and patients often face long delays and see multiple practitioners to receive a diagnosis.

OBJECTIVE

To evaluate the health care use and costs in a population-based sample of children and young people with somatic symptom and related disorders in Ontario, Canada.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used linked health and administrative databases in Ontario, Canada, where health services are funded through a universal single-payer health insurance plan. Participants included children aged 4 to 12 years, adolescents aged 13 to 17 years, and young adults aged 18 to 24 years residing in Ontario, Canada, during the period of April 1, 2008, to March 31, 2015. Included participants had a first health record diagnosis of somatic symptom and related disorders and were grouped based on the setting of their index somatic symptom and related disorders contact: outpatient, emergency department, or inpatient. Data were analyzed from August 1, 2017, to February 1, 2018.

EXPOSURES

One year before and 1 year after diagnosis of somatic symptom and related disorders.

MAIN OUTCOMES AND MEASURES

Outcome measures included overall and mental health-specific ambulatory and acute care visits and overall health system costs and sector-specific costs.

RESULTS

A total of 33 272 patients (median [interquartile range {IQR}] age, 20 [16-22] years; 17 387 female [52.3%]) were included in the analysis. Among these patients, 3875 (11.6%) were aged 4 to 12 years, 7273 (21.9%) were aged 13 to 17 years, and 22 124 (66.5%) were aged 18 to 24 years. A total of 17 893 (53.8%) had their index visit as outpatients, whereas 13 310 (40.0%) and 2069 (6.2%) were diagnosed in the emergency department and inpatient settings, respectively. Ambulatory physician visits were frequent and persisted 1 year after diagnosis within each setting (before vs after 1 year, median [IQR] visits, inpatient setting: 7 [3-13] vs 7 [3-13]; emergency department setting: 4 [2-8] vs 4 [2-9]; outpatient setting: 3 [1-7] vs 4 [2-7]; P < .001). After diagnosis, many did not receive physician-delivered mental health care (35.3% [730 of 2069] in an inpatient setting, 59.1% [7866 of 13 310] in an emergency department setting, 58.5% [10 467 of 17 893] in an outpatient setting; P < .001). Acute care use was frequent and remained so after diagnosis across settings. Of those hospitalized as inpatients at diagnosis, 37.7% (779 of 2069) were readmitted within 1 year. Mean (SD) 2-year patient costs were CAD$9845 ($39 725) (median [IQR], $2401 [$960-$7019]). Hospitalized patients had a 2-year mean (SD) cost of $51 424 ($100 416) (median [IQR], $21 997 [$12 510-$45 841]) per-patient expenditure.

CONCLUSION AND RELEVANCE

This study found that children and young people with somatic symptom and related disorders frequently used the health system with substantial health system costs before and after diagnosis. Many of these patients did not receive physician-delivered mental health care. These findings suggest that this population may be under-recognized, and initiatives for early recognition and engagement with mental health support may be warranted.

Functional Somatic Syndromes (FSS) in Children and Adolescents

Abstract. Unspecific somatic health complaints and symptoms are common in children and adolescents, varying on a continuum of severity. When persistent and impairing, they are often referred to as functional somatic syndromes (FSS). The overarching objective of this paper is to provide an overview of the pediatric literature in relation to conceptual, assessment, and treatment issues for youth presenting with FSS. Clinical recommendations are outlined including addressing potential feasibility and barrier issues for families presenting to medical and mental health services. Assessment and treatment issues are further discussed in context of two recent psychotherapy trials conducted with children and older age adolescents (aged from 7 to 19 years). Finally, we address ongoing research gaps in this field with view to strengthen the evidence base in the assessment and treatment of youth presenting with FSS.

Pediatric Consultation-Liaison Psychiatry: An Update and Review

Background

In recent years, there has been an increasing burden of child and adolescent mental illness recognized in the United States, and the need for pediatric mental health care is growing. Pediatric consultation-liaison (C-L) psychiatrists are increasingly playing a role in the management of medical and psychiatric disease for pediatric patients. The field is a fast-moving one, with understanding of new neuropsychiatric disease entities; reformulation of prior disease entities; and new interdisciplinary treatments and models of care.

Methods

In this study, we aim to review recent advances in the field of pediatric C-L psychiatry, including new diagnostic entities, updated management of frequently encountered clinical presentations, and developments in systems of care.

Conclusion

The advances in pediatric C-L psychiatry are broad and serve to promote more streamlined, evidence-based care for the vulnerable population of psychiatrically ill pediatric medical patients. More work remains to determine the most effective interventions for the wide array of presentations seen by pediatric C-L psychiatrists.

Taking the Pain out of Somatization: Development and Implementation of a Hospital-Based Clinical Practice Guideline to Address Pediatric Somatic Symptom and Related Disorders

OBJECTIVES

The diagnostic category of somatic symptom and related disorders (SSRDs), although common, is often poorly recognized and suboptimally managed in inpatient pediatric care. Little literature exists to address SSRDs in the inpatient pediatric setting. The purpose of the study was to characterize current SSRD practice, identify problem areas in workflow, and develop a standardized approach to inpatient evaluation and management at a tertiary care academic children's hospital.

METHODS

A multidisciplinary group identified patients with SSRD admitted between May 2012 and October 2014. A retrospective chart review on a convenience sample was performed to identify population characteristics and current practice. Lean methodology was used to define current state practice and future state intervention. These methods were used to guide identification of problem areas, which informed protocol, a clinical practice guideline, and resource development.

RESULTS

Thirty-six patients aged 8 to 17 years met inclusion criteria for chart review. Most patients presented with either neurologic or pain-related complaints. The mean length of stay was 5.44 days (SD = 6.3), with few patients receiving a mental health consultation within 24 hours of hospitalization. Patients averaged 5.8 medical and/or psychiatric diagnoses on discharge (SD = 5.2), and two-thirds did not have an SSRD diagnosis. Half of patients had comorbid psychiatric diagnoses, whereas one-quarter were discharged with no mental health follow-up.

CONCLUSIONS

In this study, we describe the process and content development of a single-site institutional protocol, clinical practice guideline, and resources for the evaluation and management of pediatric SSRDs. This study may serve as a model for similar standardization of SSRD care in other inpatient pediatric medical settings.