Defiance management OSCE — parent counselling and behaviour plan

Station objectives

1. Take a multi-informant-ready history of defiance with settings, duration and impairment. [4]
2. Explain the coercive cycle without blaming the parent as “the problem.” [9]
3. Counsel parent training as first-line with concrete next steps. [5] [11]
4. Plan school consistency and ADHD screening. [18]
5. Refuse inappropriate first-line antipsychotic for mild defiance and safety-net. [6]

Candidate brief

You are the doctor in a general paediatric clinic. Station A is 10 minutes with a parent. Station B is 8 minutes shared planning and counselling. The child is not present for Station B. [4]

Station A — History and formulation

Setup: Parent of a 7-year-old boy. “He never does what he’s told.” Daily arguing for over a year at home and school. No stealing or fire-setting. Time-out “doesn’t work” — parent often gives up. Teacher emails about talking back. Parent asks “can he just have something for it?” [4]

Expected actions:

• Elicit onset, frequency, settings, impairment, and what has been tried. [4]
• Ask school function, friendships, learning and possible ADHD features. [18]
• Map coercive cycle: demand → escalation → parent withdraws or explodes. [9]
• Screen safety: aggression to siblings, weapons, caregiver violence, self-harm. [4]
• Avoid diagnosing CD without criterion behaviours; avoid calling the child “bad.” [4]
• Summarise: multi-setting ODD-range pattern with coercive maintainers; need parent skills and school plan; ADHD assessment indicated. [4] [18]

Station B — Plan counselling

Setup: Parent returns for plan. Still wants “a tablet today.” Parent training waitlist is long. [5]

Expected actions:

• Explain first-line behavioural parent training and why it works (skills + contingencies, not lectures alone). [5] [11]
• Offer interim coaching: specific commands, catch good behaviour, consistent follow-through, reduce public battles. [11]
• Agree two functional goals (e.g. morning routine; fewer office referrals). [5]
• Plan school liaison with consistent adult responses. [4]
• Explain ADHD assessment pathway if features present; treating ADHD may reduce secondary oppositionality. [18]
• Decline antipsychotic for mild defiance; explain specialist role only for severe aggression after psychosocial care, with monitoring. [6]
• Safety-net: when to re-present for escalating violence, injuries, or family safety concerns. [4]
• Teach-back: parent restates the plan in their own words. [5]

Marking domains

Examiner notes — common fails

• Starting risperidone because the waitlist is long. [6]
• Blaming the parent as solely responsible without offering skills. [9]
• Missing ADHD features. [18]
• Equating defiance with CD. [4]
• No school plan. [4]
• No safety questions. [4]