Post-traumatic stress disorder and trauma responses — OSCE

Candidate information (2 minutes reading, 12 minutes station)

You are the general paediatric registrar in an outpatient clinic. Liam, aged seven, is brought by his mother six weeks after a serious car crash. Read the presentation, then conduct the assessment and counselling. The examiner will role-play the mother. [1] [11]

Candidate tasks

1. Take a focused trauma-informed history from the mother and (adapted to the child) from Liam — characterise the event, the symptom clusters, the timeline, and the functional impact. [8] [12]
2. Establish the diagnosis and level of care: distinguish expected acute stress reaction from Acute Stress Disorder and PTSD using time, the four clusters, and impairment. [7] [11]
3. Counsel the mother on first-line management, and specifically address her request for a counsellor to "debrief him properly." [1] [10]
4. Respond to the safeguarding disclosure of parental alcohol misuse and domestic risk, and formulate a safe disposition. [9] [11]

Marking anchors

Distinction (PASS)

• Uses time, the four clusters, and functional impairment to separate an expected reaction (resolving within days–weeks), Acute Stress Disorder (3 days–1 month), and PTSD (> 1 month + impairment) — and correctly labels Liam as PTSD because six weeks have elapsed and school and social function are impaired. [7] [11]
• Elicits all four clusters with developmental framing: intrusion as nightmares and repetitive traumatic play/drawings (not just verbal flashbacks), avoidance of cars, negative mood and social withdrawal, and arousal with sleep and concentration disturbance. [2] [12]
• States trauma-focused CBT as first-line (roughly 8–16 sessions, psychoeducation, parenting, gradual exposure and trauma narrative, cognitive restructuring, affect regulation, in-vivo mastery, caregiver integral to the paediatric model), citing the Cohen RCT as foundational evidence. [1] [12]
• Explicitly advises against single-session debriefing when the mother requests it, explaining the evidence shows no benefit and possible harm; offers psychological first aid and watchful waiting as the correct early frame, and TF-CBT now that symptoms are persistent. [10] [11]
• Does not recommend an SSRI first-line for this prepubertal child; knows SSRIs are adjunctive only in adolescents with persistent symptoms or comorbid depression under specialist care. [12]
• Converts for safeguarding: recognises the partner's ongoing intoxication and anger as a potential domestic-violence and child-safety risk, prioritises immediate safety, does not begin exposure-based trauma work in an unsafe environment, and arranges child-protection involvement and a same-day safety plan. [9] [11]
• Closes the loop with a named clinician owner, follow-up date, school liaison, GP coordination, and a clear safety-net for what should bring the family back sooner. [11]

Borderline

• Labels PTSD correctly but cannot articulate the time thresholds or clusters precisely. [7]
• Offers TF-CBT but fails to address the debriefing request or the SSRI question. [10] [12]
• Notes the safeguarding concern but does not act on it or convert the plan. [9]

Fail

• Forces a PTSD label onto what they call a "normal reaction" despite six weeks of impairment, OR misses PTSD entirely. [7]
• Recommends single-session debriefing as prevention, or starts an SSRI first-line for a prepubertal child. [10] [12]
• Begins exposure-based trauma work without addressing the ongoing domestic risk, or fails to make a mandatory-reporting / child-protection referral when thresholds are met. [9] [11]

Examiner prompt sequence

1. Opening (the mother): "Doctor, does Liam have PTSD from the crash?" — Candidate must explain the continuum and the time/impairment threshold in plain language. [7] [11]
2. The debriefing request: "A friend said a counsellor should debrief him properly so it doesn't get worse — can you arrange that today?" — Candidate must decline single-session debriefing with evidence and offer the correct pathway. [10] [11]
3. The medication question: "Should he go on something to help him sleep and calm down?" — Candidate must explain why an SSRI is not first-line in prepubertal PTSD and that sleep and arousal are addressed within TF-CBT. [12]
4. The safeguarding disclosure: "I have to tell you — the crash was because my partner was drunk and furious. He's still drinking every night." — Candidate must convert to a safety-and-child-protection pathway, document, and arrange support for mother and child. [9] [11]
5. Wrap-up: "So what happens next, and who do I call?" — Candidate must close the loop with a named owner, follow-up, school liaison, and a written safety-net. [11]