Explain childhood anxiety and the stepped-care plan to parents — OSCE

Candidate instructions

Explain that anxiety disorders are real, common and treatable (not bad parenting or attention-seeking), outline the worry cycle and how exposure-based CBT helps the brain learn the threat is survivable, discuss reducing accommodation without blame, cover when an SSRI such as sertraline might be added and how you monitor for activation and suicidal thoughts, check understanding, and agree a shared plan. The examiner plays a parent. [1] [2] [3]

Candidate scenario

You are the paediatrician in clinic. Parents of a 12-year-old with separation and social anxiety, partial school attendance, and weekday morning stomach aches that remit at home ask whether the problem is "real" and whether they caused it. There are no medical red flags after review and no active suicide plan. School is willing to meet this week. [2] [5]

Marking domains

• Empathy, structure and agenda-setting (including parental guilt)
• Accurate plain-language model: anxiety as a real, common, treatable disorder; the worry cycle
• Clear explanation of exposure-based CBT as graded supported steps, and reducing accommodation without blame
• Balanced SSRI discussion (when it is considered; CAMS combination rationale in simple terms)
• Monitoring for activation and suicidal thoughts; early review plan
• Safety-net and shared written plan with a school meeting date

Model outline

Open. Name and normalise the problem without blame: "Anxiety disorders are the most common mental health problem in children, and they are real and treatable. What your child is feeling is a genuine alarm system firing too hard, not attention-seeking and not something you caused. About one in three teenagers will have one." [2] [5]

The worry cycle. "When the alarm fires, your child feels it in the body — stomach aches, racing heart — and avoids the thing that set it off. Avoiding brings quick relief, so the brain learns avoidance is the answer. That relief is actually what keeps the anxiety going. Our job is to gently break that loop." [2]

CBT and accommodation. "Treatment is small, supported steps back toward the feared situation, with coping skills — never throwing them in the deep end. Exposure-based CBT is the first-line therapy and has good evidence. Your role is coach: fewer last-minute cancellations and less rearranging life around the fear, which we call accommodation. You have been doing that out of love, and it is completely understandable — but it can keep the anxiety going, so we will work on it together." [2] [3]

Medication. "If the anxiety stays high despite good therapy, or if it is severe, an SSRI such as sertraline can help the alarm settle. A large study called CAMS found that therapy plus sertraline helped more young people than either alone. So medicine is for the anxiety when it is moderate or severe, not a quick fix. We start low — 25 milligrams once a day — go slow, and review early." [1] [2]

Safety monitoring. "A small number of young people can feel more agitated or have new thoughts of self-harm when antidepressants start. It is uncommon but important, so we watch closely, especially in the first couple of weeks and after any dose increase, and you contact us urgently if mood or safety changes." [4]

Close. Written plan: multi-informant assessment with a scale such as SCARED, school meeting this week, graded steps, who to call if risk rises, and a review date. Invite questions and check understanding. [2] [5]