Paeds · clinical-assessment-and-reasoning
Multimorbidity and diagnostic overshadowing in children
Also known as Paediatric multimorbidity · Childhood multimorbidity · Diagnostic overshadowing · Physical-mental multimorbidity · Co-occurring conditions · Polypharmacy and multimorbidity · Second diagnosis missed
Fellowship approach to paediatric multimorbidity and diagnostic overshadowing: definitions versus comorbidity and CMC, physical-mental co-occurrence, cognitive traps that hide second diagnoses, baseline-aware assessment, polypharmacy safety, pain and behaviour as medical data, residual-risk communication and exam-ready reasoning.
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Target exams
Red flags
- New change blamed entirely on a known diagnosis or disability label
- Behaviour, self-injury or sleep disruption without a medical search for pain or illness
- Caregiver concern that the child is not their usual self, even if numbers look near baseline
- Polypharmacy cascade: each new symptom treated with another medicine and no review
- Neuroregression, catatonia or progressive signs mislabelled as baseline autism or intellectual disability
- Handover that closes residual risks after a single-label discharge
- Discrimination or lower urgency because the child is ‘always complex’
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Current 2026 PREP curriculum — Learning Objective related to chronic complex care and disability
- Renewed curriculum for first-year trainees from 2027 — Learning goal 5: Clinical assessment – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Clinical management – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 10: Clinical assessment and management – developmental and behavioural paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 12: Communication with patients, families, and health professionals
- Renewed curriculum for first-year trainees from 2027 — Learning goal 15: Essential general paediatrics
- Clinical Applications
- Long Cases
- Short Cases
- 2. Professional skills and knowledge: Communication
- 4. Professional skills and knowledge: Patient management
- 6. Leadership and team working
- 7. Patient safety, including safe prescribing
- Health promotion and illness prevention
- General Paediatrics: Coordinates care for children and young people with complex needs
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- General Pediatrics Content Outline — Domain related to chronic disease, disability and complex care
- General Pediatrics Content Outline — Domain 24: Patient Safety, Quality Improvement, and Research Methods
- General Pediatrics EPA: Provide a medical home for patients with complex, chronic, or special health care needs
- General Pediatrics EPA 8: Executing Clinical Handovers Within or Across Settings
- General Pediatrics EPA 10: Leading Interprofessional Teams to Provide Collaborative, Family-Centered Care
- Patient Care 3: Organize and Prioritize Patient Care
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Patient Management
- Systems-Based Practice 1: Patient Safety
- Systems-Based Practice 3: System Navigation for Patient Centered Care – Coordination of Care
- Interpersonal and Communication Skills 1: Patient- and Family-Centered Communication
- Medical Expert
- Pediatrics: Core EPA #11 — Coordinating transitions of care for patients with medical or psychosocial complexity
- Pediatrics: Foundations EPA #8 — Communicating assessment findings and management plans to patients and/or families
- Pediatrics: Foundations EPA #10 — Transferring clinical information between health care providers during handover
Overview & Definition
Picture a 9-year-old with cerebral palsy, epilepsy, gastrostomy feeds and constipation. Tonight the usual carer says she is quieter, biting her hand and not smiling. A junior note reads “behavioural — known disability.” That sentence can delay the search for tooth pain, urinary retention, shunt failure or a new infection. The clinical job is not to ignore the known diagnoses. The job is to hold them and still ask what else is new. [1] [13] [24]
Multimorbidity means two or more chronic conditions coexist in one child. No single “index disease” is required for the definition. That framing differs from comorbidity, which usually means a secondary condition attached to one primary disease. Both words appear in papers. At the bedside, use multimorbidity when several active problems share ownership of the child’s risk. [6] [7]
Diagnostic overshadowing is the cognitive error first framed experimentally by Reiss and colleagues: the presence of intellectual disability reduces the likelihood that clinicians will diagnose a coexisting emotional or behavioural disorder. Later work extended the idea beyond psychiatry. Any strong label — autism, “complex child,” “baseline seizures,” “always chesty” — can hide a second treatable process. Jopp reviewed the construct. Dell’Armo’s systematic review and later experimental work show the bias remains relevant for psychological disorders in people with intellectual disability. [1] [2] [3] [4]
Children with medical complexity (CMC) are a related but narrower population. Cohen’s domains combine chronic conditions, functional limits, high health-care use and family-identified needs. Kuo’s AAP report turns that into recognition and management work. Many CMC children have multimorbidity. Not every multimorbid child meets CMC criteria. Atopic multimorbidity (asthma, eczema and allergic rhinitis together) is common and usually not CMC. Keep the frames separate so you choose the right tools. [9] [10]
Write a problem representation the way you would hand over: age; active conditions that matter today; personal baseline; what changed; whether the threat looks like flare, new illness, medicine harm or an overshadowed process; residual risks still open; and what you need next. [14] [21]
References24ShowHide
- [1]Reiss S, Levitan GW, Szyszko J Emotional disturbance and mental retardation: diagnostic overshadowing. American journal of mental deficiency, 1982.PMID 7102729
- [2]Jopp DA, Keys CB Diagnostic overshadowing reviewed and reconsidered. American journal of mental retardation : AJMR, 2001.PMID 11531461
- [3]Dell'Armo K, Tassé MJ Diagnostic Overshadowing of Psychological Disorders in People With Intellectual Disability: A Systematic Review. American journal on intellectual and developmental disabilities, 2024.PMID 38411245
- [4]Dell'Armo K, Tassé MJ How intellectual disability may bias psychologists' clinical impressions: An examination of diagnostic overshadowing. Psychological assessment, 2025.PMID 40167540
- [5]Manohar H, Subramanian K, Kandasamy P, et al. Diagnostic Masking and Overshadowing in Intellectual Disability-How Structured Evaluation Helps. Journal of child and adolescent psychiatric nursing, 2016.PMID 27901303
- [6]Romano I, Buchan C, Baiocco-Romano L, et al. Physical-mental multimorbidity in children and youth: a scoping review. BMJ open, 2021.PMID 34016659
- [7]Ferro MA, Qureshi S, Van Lieshout RJ, et al. Prevalence and Correlates of Physical-mental Multimorbidity in Outpatient Children From a Pediatric Hospital in Canada. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 2022.PMID 35060408
- [8]Ferro MA, Qureshi SA, Shanahan L, et al. Health-related quality of life in children with and without physical-mental multimorbidity. Quality of life research, 2021.PMID 34331638
- [9]Cohen E, Kuo DZ, Agrawal R, et al. Children with medical complexity: an emerging population for clinical and research initiatives. Pediatrics, 2011.PMID 21339266
- [10]Kuo DZ, Houtrow AJ Recognition and Management of Medical Complexity. Pediatrics, 2016.PMID 27940731
- [11]Feinstein JA, Orth LE Making Polypharmacy Safer for Children with Medical Complexity. The Journal of pediatrics, 2023.PMID 36252865
- [12]Orth LE, Feudtner C, Kempe A, et al. A coordinated approach for managing polypharmacy among children with medical complexity: rationale and design of the Pediatric Medication Therapy Management (pMTM) randomized controlled trial. BMC health services research, 2023.PMID 37120509
- [13]Hauer J, Houtrow AJ Pain Assessment and Treatment in Children With Significant Impairment of the Central Nervous System. Pediatrics, 2017.PMID 28562301
- [14]Bordini BJ, Stephany A, Kliegman R Overcoming Diagnostic Errors in Medical Practice. The Journal of pediatrics, 2017.PMID 28336147
- [15]Berkwitt A, Grossman M Cognitive bias in inpatient pediatrics. Hospital pediatrics, 2014.PMID 24785565
- [16]Croskerry P, Singhal G, Mamede S Cognitive debiasing 1: origins of bias and theory of debiasing. BMJ quality & safety, 2013.PMID 23882089
- [17]Mills E, Lin P, Asghari-Jafarabadi M, et al. Association between caregiver concern for clinical deterioration and critical illness in children presenting to hospital: a prospective cohort study. The Lancet. Child & adolescent health, 2025.PMID 40451224
- [18]Cook S, Mauskar S, Berry JG Discriminating Against Children With Medical Complexity. Pediatrics, 2023.PMID 37357723
- [19]Yin HS, Neuspiel DR, Paul IM, et al. Preventing Home Medication Administration Errors. Pediatrics, 2021.PMID 34851406
- [20]Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. The New England journal of medicine, 2014.PMID 25372088
- [21]Bowen JL Educational strategies to promote clinical diagnostic reasoning. The New England journal of medicine, 2006.PMID 17124019
- [22]Reinfeld S, Gill P Diagnostic overshadowing clouding the efficient recognition of pediatric catatonia: a case series. CNS spectrums, 2023.PMID 36440510
- [23]Loo KK, Cheng J, Sarco D, et al. Diagnostic Overshadowing: Insidious Neuroregression Mimicking Presentation of Autism Spectrum Disorder. Journal of developmental and behavioral pediatrics : JDBP, 2022.PMID 35943376
- [24]Yekezare M, Handley P, Clough S Diagnostic overshadowing: self-injurious behaviour as a manifestation of pain in the head and neck. British dental journal, 2024.PMID 38877248