Emergency Department and Inpatient Clinical Pathway
for Somatic Symptom and Related Disorders

Goals and Metrics
Patient Education
Provider Resources
  • 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.
Child with Suspected Somatic Symptom and Related Disorder (SSRD) Based on Initial History and Physical Exam
  • 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
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
Discharge/Follow-up
Preparation for Admission (ED Team)
  • 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
  • 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
Inpatient Management
  • 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