Psychological impact of chronic illness and disability — branching viva

Station 1 — Opening presentation (set the frame)

A 14-year-old with type 1 diabetes has a rising HbA1c, has missed three months of school, and is withdrawn. What is going on, and what is your framework? [4]

Expected answer: Recognise this as the psychological impact of a chronic illness, not a metabolic problem. Apply the biopsychosocial model (biological, psychological, social, system domains) and lead with the resilience-oriented principle: most chronically ill children adapt well, so the strategy is routine screening, not reactive referral. [4] [2]

Station 2 — The adjustment-to-disorder continuum

Where is this child on the continuum, and what is the gate question? [5]

Expected answer: Place her on the continuum from healthy adjustment, through an adjustment distress reaction, a subthreshold/risk state, to a diagnosable psychiatric disorder. The gate question is "does this meet DSM-5-TR criteria for a disorder?" — persistent anhedonia, hopelessness, sleep and appetite disturbance and functional decline for at least two weeks cross into a major depressive disorder regardless of the illness. The chronic illness explains the stressor; it does not exempt the child from the diagnosis. [5]

Station 3 — Mechanism: why is outcome "mediated"?

Explain the disability-stress-coping cascade. What is the modifiable mediator? [3]

Expected answer: The illness is a sustained stressor; outcome depends on appraisal and coping, moderated by family functioning, self-efficacy, support and adherence — hence mediated, not determined. Coping is the modifiable mediator: problem-focused, engaged coping predicts adaptation; avoidance and disengagement predict deterioration. Describe the maintaining feedback loop (low mood → non-adherence → worse control → disruption → deeper low mood) and that breaking any node helps. [2] [3]

Station 4 — The stepped plan

Build the management plan. [4]

Expected answer: A three-tier, family-centred, school-inclusive pathway. Tier 1 universal — validate, psychoeducate, screen routinely, build the plan with the young person, promote coping/connection/participation. Tier 2 targeted — brief CBT/coping skills, graded return to activity, family/parenting support, school liaison with a written education/health plan, treat pain and sleep. Tier 3 specialist — refer to CAMHS for a disorder; an SSRI is specialist-initiated, only for a confirmed disorder, monitored. The paediatrician coordinates. Name the school-reintegration plan as the strongest functional lever. [4] [6]

Station 5 — Diagnostic overshadowing challenge

Now: a non-verbal 15-year-old with cerebral palsy has become agitated and is sleeping poorly; the carers say "it's just her disability." What is the risk, and what do you do? [1]

Expected answer: Name diagnostic overshadowing — attributing a new presentation to the disability and missing a treatable disorder. The safeguard is to run the same differential as for any child: look first for treatable physical causes (pain, seizures, reflux, constipation, side-effects), then psychological causes (depression, anxiety, procedural trauma), then social causes. Adapt assessment for impaired communication with observation and informant report. Do not anchor on the disability. [1] [2]

Station 6 — Suicide-risk interrupt

She discloses, in a different patient, that she "doesn't want to be here anymore." What now? [5]

Expected answer: Treat this as an immediate emergency that bypasses routine pathways. Assess suicidal ideation, intent, plan and access to means; build a safety plan; arrange same-day urgent mental-health assessment; do not leave her alone; involve the family within the bounds of safety. Chronic illness raises suicide risk, and disclosed ideation overrides every other clinical priority. [5]