Multimorbidity and diagnostic overshadowing in children — formative SAQs

SAQ 1 — Definitions and problem representation (10 marks)

A 9-year-old has epilepsy, GORD, chronic constipation and anxiety. She presents with new self-injury and reduced interaction. A triage note says “known complex — behavioural.” [1] [10]

Questions

1. Define multimorbidity and diagnostic overshadowing in one sentence each, and state how they differ from comorbidity and from CMC. (4 marks) [1] [6] [10]
2. Write a one-sentence problem representation for this encounter. (3 marks) [14]
3. List four residual risks that must stay open if a behavioural working label is used. (3 marks) [13] [24]

Model answer

Definitions (4). Multimorbidity: two or more concurrent chronic conditions in one child. Diagnostic overshadowing: a known disability or disease label reduces recognition of a second condition. Comorbidity usually frames a secondary condition on an index disease. CMC is a narrower high-need construct (chronic conditions, functional limits, high use, family needs) and is not identical to multimorbidity. [1] [6] [10]

Problem representation (3). Nine-year-old with multimorbidity (epilepsy, GORD, constipation, anxiety) and new self-injury plus reduced interaction from baseline; risk of overshadowing a medical driver of pain or illness; requires structured medical search and open residual risks rather than a closed behavioural label. [14] [17]

Residual risks (3). Any four of: dental/ENT/head-neck pain; constipation or urinary retention; new infection or decompensation; medication toxicity or missed doses; seizure cluster or post-ictal change; safeguarding injury; progressive neurological process. [13] [24] [11]

SAQ 2 — Debiasing, medicines and communication (10 marks)

The same child is on six regular medicines. The usual carer says she is “not herself.” First observations are near her usual band. [11] [17]

Questions

1. Outline a diagnostic pause and threat-first differential of up to five items. (4 marks) [14]
2. State three polypharmacy safety actions you will take now. (3 marks) [11]
3. Give a one-paragraph communication script that names residual risk and safety-net. (3 marks) [17] [20]

Model answer

Pause and differential (4). Pause: what else could this be; what would change my mind; who else should look; what residual risk stays open. Differential prioritised by threat: pain (including dental/abdominal), constipation/retention, infection, medication effect or error, seizure-related change; keep safeguarding open as context requires. Do not end on “behavioural baseline.” [13] [14] [24]

Polypharmacy actions (3). Full reconciliation with doses and recent changes; review indication and interactions; plan deprescribing or simplification when safe; teach/check home administration technique and supply. [11]

Communication (3). “I think the most likely problem is X on her known conditions. I am still protecting against pain, infection and medicine effects. We will examine and test for those now. Call back or return if she is less interactive, pain behaviours worsen, breathing changes, medicines cannot be given, or you are more worried — including tonight.” Acknowledge carer expertise. [17] [20]