Psychological impact of chronic illness and disability — formative SAQs

SAQ 1 — 14-year-old with type 1 diabetes, rising HbA1c, school absence and withdrawal (10 marks)

A 14-year-old girl with type 1 diabetes has a climbing HbA1c, has missed three months of school, and is described by her mother as "flat and withdrawn." She has no current suicidal ideation on direct questioning. [4] [6]

Questions

1. Using a biopsychosocial, resilience-oriented model, outline your assessment of her psychological state, naming the screening instruments you would use and the red flags you must ask about. (5 marks) [4] [2]

2. Describe the stepped, family-centred and school-inclusive management plan you would build, and justify why the outcome is described as "mediated" rather than "determined." (5 marks) [3] [9]

Model answer

Assessment (5). Frame the assessment with the biopsychosocial model — biological (the illness, its burden, visibility, unpredictability), psychological (coping, mood, self-esteem, body image), social (family, peers, school) and system (access, inclusion) — and state the resilience-oriented principle that most children adapt well, which is why routine screening, not reactive referral, is the strategy. [2] [4]

Take the history from the young person alone where possible, using an adapted HEEADSSS, and explicitly ask about mood, sleep, coping, body image, peers, bullying, school attendance and adherence; ask directly and specifically about suicidal ideation, because chronic illness raises suicide risk and direct questioning is safe and high-yield. Use standardised screens — the SDQ for broad emotional/behavioural problems, the PHQ-A (or PHQ-9 modified for adolescents) for depression, the GAD-7 for anxiety, and the PedsQL to quantify health-related quality of life and function — and state that screening is repeated over time, not done once. [4] [7]

Distinguish an expected adjustment reaction from a depressive disorder using the gate question "does this meet DSM-5-TR criteria?" — persistent anhedonia, hopelessness, sleep/appetite disturbance and functional decline, present most of the day for at least two weeks, cross the threshold into a disorder. Decode the non-adherence (omission for weight, burnout, cost, family disorganisation) rather than labelling it "non-compliance," and assess the family: parenting stress is common, parental mental health matters, and a burning-out family cannot sustain the care plan. [6] [8]

Management (5). Apply a three-tier stepped pathway. Tier 1 is universal and yours: validate the experience, give honest psychoeducation that normalises the reaction, flag the attendance and adherence early, and build the plan with the young person, promoting coping, connection and participation. Tier 2 is targeted for her emerging distress: brief CBT or coping-skills work, problem-solving and a graded return to activity, family and parenting support, a structured school-reintegration plan with a named school and clinical contact, and active treatment of pain and sleep. Tier 3 is specialist referral to child and adolescent mental-health services if she meets criteria for a depressive or anxiety disorder; an SSRI would be considered by a specialist only for a confirmed disorder, started where indicated and monitored. [3] [9]

Justify "mediated, not determined": the disability-stress-coping model holds that the illness is a sustained stressor, but the outcome depends on appraisal and coping, moderated by family functioning, self-efficacy and support — a child with severe illness and strong mediators can adapt better than one with mild illness and broken mediators. The maintaining feedback loop (low mood → non-adherence → worse control → more disruption → deeper low mood) is why intervention at any node helps, and it is the reason the paediatrician's assessment genuinely changes the trajectory. [2] [3]

SAQ 2 — Non-verbal adolescent with cerebral palsy and a behaviour change, and a safeguarding-adjacent scenario (10 marks)

Part A (5 marks): A 15-year-old with severe cerebral palsy and no verbal communication, previously settled, has become agitated, is sleeping poorly, and has stopped engaging at school. Her carers say "it's just her disability." [1] [2]

1. Discuss the concept of diagnostic overshadowing as it applies here, and outline your assessment and initial management. (5 marks) [1] [2]

Part B (5 marks): Separately, the sibling of a child with a complex chronic condition has been missing school, is irritable, and tells you "no one ever asks about me." [8]

2. Outline the impact of chronic illness on siblings and the family system, and your response. (5 marks) [8]

Model answer

Part A — Diagnostic overshadowing (5). Diagnostic overshadowing is the error of attributing a new physical or psychological presentation to the underlying disability, and thereby missing a treatable disorder — here, agitated behaviour, poor sleep and disengagement are being dismissed as "just her disability." The safeguard is a discipline: every new symptom in a disabled child gets the same differential it would in an unaffected child. [1] [2]

Assess across the biopsychosocial domains and adapt for impaired communication: use structured observation, informant report and behaviour as well as any self-report, because standard self-report screens underperform in non-verbal youth. Look for a treatable physical cause first (pain — including hip dislocation, reflux, constipation, dental disease, UTI — seizures, and medication side-effect), then a psychological cause (depression, anxiety, medical or procedural trauma), then a social cause (changes in care, placement, school or bereavement). Investigate the targeted differential honestly; do not anchor on "the disability." [2] [4]

Initial management is to treat any reversible cause found, deliver universal supportive care (validate, reassure, optimise comfort and communication), and refer for specialist psychological and complex-care support if distress persists — coordinating with the disability team rather than discharging the mental-health question back to them. [2]

Part B — Sibling and family impact (5). Chronic illness affects the whole family system, not only the child. Siblings carry their own adjustment burden — they are often given less attention, may feel guilt, resentment or anxiety, and can show emotional and behavioural problems and school disengagement, as the sibling literature within the chronic-illness field establishes. Parenting stress is measurable and common in caregivers of children with chronic conditions, and parental depression and burnout feed back to worsen the affected child's outcome. [8] [5]

Your response is to assess the family as a unit of care, not an aside: ask directly about parental mental health, the sibling's wellbeing, and the practical and financial strain; validate the sibling's experience ("I am asking about you"); and refer parents and siblings for support in their own right. Recognise that a family that has broken under the strain cannot sustain the care plan, so family support is part of the treatment for the affected child, not an optional extra. [8] [4]