Leveraging medical, rehabilitation, and mental health expertise for integrated care pathways for pediatric somatic symptom and related disorders.

Introduction: In pediatric somatic symptom and related disorders (SSRDs), children and adolescents experience and express distress through physical symptoms, leading to functional impairment. Symptoms can vary widely and may affect multiple systems, including the neurological, musculoskeletal, and gastrointestinal systems. Care for children with SSRDs is fragmented, poorly integrated, with only 40% of affected children receiving timely mental health care. Many also experience social isolation and school absenteeism and undergo unnecessary medical tests and procedures. The heterogeneity in symptom presentation and the stigma of mental illness can prolong the diagnostic journey and stall engagement in evidence-based treatments. We outline the development and share experiences from the first 18 months of implementation of an interdisciplinary care pathway at a tertiary care centre where diagnosis and treatment services are aligned with a patient’s readiness to identify functional goals and engage in mental health treatments.

Methods: Following two years of environmental scans and stakeholder feedback, we formed an interdisciplinary care team comprised of pediatricians, psychiatrists, care managers with nursing skill sets, occupational and physical therapists, psychologists, and social workers. All patients referred with suspected SSRDs underwent physician assessments (by either a pediatrician or psychiatrist) to confirm diagnoses, identify the biological, psychological, and social contributors to the clinical presentation, provide initial psychoeducation to the family, and evaluate readiness to engage in rehabilitation and mental health treatment. Patients and families were streamed either directly to group mental health therapies heavily focused on psychoeducation with/without rehabilitation or, when not ready, to a care manager for ongoing support, psychoeducation, care coordination, and system navigation +/- rehabilitation. Those in this latter stream were comanaged directly by a pediatrician and indirectly by a psychiatrist/psychologist through clinician-to-clinician consultation and interdisciplinary team rounds until they were ready for direct mental health treatment. 

Results: In the initial 18 months, 244 patients were engaged through this integrated care pathway (median age 15.0 years IQR 12.1-16.3; 70% female). The care managers had 390 patient contacts for 108 unique patients. One hundred and thirty-five patients or their caregiver attended at least one initial psychoeducation workshop. Rehabilitation support was refined to a mean of 4.7 visits (SD 2.9) per patient. There were 23 interdisciplinary case conferences discussing 39 patients. Sixty-five eligible individuals attended group mental health treatment. Caregivers and patients reported positive experiences, noting clear diagnoses and organized, personalized care. Providers valued the pathway for its coordination and communication improvements. However, both families and providers identified a need for ongoing mental health support following initial treatments in the pathway. Preliminary evaluations suggest reductions in unplanned emergency department visits, inpatient admissions, and medical testing, indicating the pathway's effectiveness in addressing SSRDs in children.

Implications: We have leveraged our medical, rehabilitation, and mental health expertise at a tertiary care centre to provide integrated interdisciplinary care to children with SSRDs. Following iterative adjustments to the model care pathways, patients, families, and clinicians report improved processes, experiences, and outcomes. Future directions include further expansion to include other service areas and to build capacity with community partners outside of tertiary care