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type 1 diabetes has a climbing HbA1c, has missed three months of school, and is described by her mother as "flat and withdrawn."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 reason paediatrician's assessment genuinely changes the trajectory. ^{[2] [3]}