Attachment disorders and relational trauma — OSCE

Candidate information (2 minutes reading, 12 minutes station)

You are the general paediatric registrar in an outpatient clinic. Marcus, aged four, is brought by his foster carer Aroha six weeks after placement following chronic neglect. Read the presentation, then conduct the assessment and counselling. The examiner will role-play Aroha. [1] [13]

Candidate tasks

1. Take a trauma-informed caregiving and behavioural history from Aroha — establish the pathogenic care, map the withdrawn/inhibited and indiscriminate patterns across carers and settings, and assess development and carer capacity. [1] [2]
2. Frame the likely diagnosis in plain language — reactive attachment disorder with probable coexisting disinhibited social engagement disorder — and explain that the relationship, not Marcus alone, is the treatment focus. [3] [13]
3. Counsel on treatment: name an evidence-based relationship intervention (ABC or Child-Parent Psychotherapy), explain there is no first-line medication, and explicitly advise against coercive 'holding therapy'. [7] [9] [13]
4. Convert to a safeguarding pathway when the contact-visit bruising is disclosed, and close the loop with child protection, the carer, and the school. [13]

Marking anchors

Distinction (PASS)

• Uses the behavioural pattern plus the caregiving-history gateway to name reactive attachment disorder and probable disinhibited social engagement disorder, and explicitly states that neither is diagnosable without grossly pathogenic care. [1] [2]
• Counsels that the relationship is the treatment: names ABC or CPP as the evidence-based intervention with the dyad, states there is no first-line medication, and clearly warns Aroha against coercive 'holding therapy'. [7] [9] [13]
• Converts the whole plan to a child-protection pathway the moment the contact-visit bruising surfaces — immediate safety, mandatory reporting via the local pathway, and a same-day safety plan — because relationship work cannot run while Marcus is being harmed. [13]
• Supports the carer explicitly (Aroha is tearful and exhausted) and closes the loop with a named owner, follow-up, and coordination with child protection, school, and the GP. [13]

Borderline

• Names the disorder but cannot articulate the two-disorder structure or the caregiving-history gateway precisely, or recommends relationship therapy without converting to safeguarding. [2]

Fail

• Diagnoses on a single observation, blames Aroha for the behaviours, starts an SSRI to 'treat' the attachment disorder, endorses or fails to warn against 'holding therapy', or proceeds to 'refer for attachment counselling and review' despite the disclosed contact-visit bruising. [13]

Examiner prompt sequence

1. Opening (the carer): "Doctor, can you start something to help him attach?" — Candidate must explain the two-disorder structure and that the relationship, not a drug, is the treatment. [1] [13]
2. The holding-therapy prompt: "A friend said holding therapy forces the bond — should I try it?" — Candidate must decline clearly and name an evidence-based alternative. [13]
3. The medication prompt: "Surely an SSRI would take the edge off?" — Candidate must state no first-line medication for the attachment disorder itself. [13]
4. The safeguarding disclosure: "He comes back from contact with new bruises and is scared for days." — Candidate must convert to child protection and a same-day safety plan. [13]