Youth violence, risky behaviour and injury prevention OSCE — private screening, tiering, lethal-means counselling and the safety override

Station objectives

1. Secure time alone and state conditional confidentiality with its limits. [9] [3]
2. Complete a private, developmentally framed violence and safety screen woven into HEeADSSS. [9]
3. Stratify the young person into a prevention tier and match the intervention to the evidence. [4] [8]
4. Perform lethal-means counselling and recognise the immediate-safety override. [6] [7]

Candidate brief

You are the paediatric doctor in a youth-friendly clinic. You have 10 minutes for Station A (private prevention assessment and brief advice) and 12 minutes for Station B (post-overdose adolescent, lethal-means counselling and disposition). Examiners score process, safety, partnership language, and the quality of the prevention plan. [9] [3]

Station A — Bullying, vaping, and a firearm in the home

Setup: A 15-year-old, seen alone after the parent steps out, has been bullied at school and now avoids attending, vapes nicotine occasionally, and mentions there is a loaded, unlocked firearm at home "for protection." They have low mood but no current plan. [11] [6]

Expected actions:

• Confirm confidentiality and its limits; greet the young person first and centre their account. [9]
• Complete the violence and safety screen: bullying both ways (including cyberbullying), dating violence, fighting and weapon-carrying, road risk, self-harm, and access to lethal means. [11] [13]
• Assess suicide risk fully given the low mood: ideation, plan, intent, prior attempts, means, protective factors, ability to keep safe. [7]
• Counsel safe firearm storage (locked, unloaded, ammunition separated) and arrange temporary removal if suicide risk is present; frame it with the family as a safety measure, not a punishment. [6] [7]
• Plan a safe, agreed school response to the bullying with the young person's agreement; brief strengths-based advice on vaping using motivational-interviewing technique. [11] [8]

Station B — Post-overdose adolescent with firearm access

Setup: A 17-year-old is medically stable in the emergency department after an overdose. They have a firearm at home and describe passive suicidal ideation. They ask you not to tell their parent. [7] [6]

Expected actions:

• Confirm physiology is stable; complete a same-visit suicide risk assessment (ideation, plan, intent, prior attempts, means, protective factors, ability to keep safe). [7]
• Provide lethal-means counselling and arrange temporary removal of the firearm from the home before discharge. [6] [7]
• Activate the crisis or mental-health pathway; build a written safety plan with who to call tonight; do not discharge on a promise of safety alone or on delayed psychology. [7]
• Explain confidentiality reasoning: serious risk of harm overrides confidentiality; share the minimum necessary and tell the young person what must happen and why. [3]

Marking anchors

Clear pass: secures time alone and conditional confidentiality; structured private violence and safety screen across all domains; correct tiering and evidence-matched prevention; lethal-means counselling with temporary removal when indicated; same-visit action on any positive lead; clear confidentiality reasoning; urgent disposition with follow-up loops closed. [9] [6] [8] Borderline: good rapport but incomplete screening (misses weapons, dating violence or means), vague follow-up, or prevention advice limited to one domain. Fail: no private time; punitive or judgemental stance; files a disclosure without acting; ignores suicide risk or firearm access; breaks confidentiality inappropriately or refuses to break it when safety demands. [7] [3]

Debrief pearls

• Violence and injury are health problems, not character problems; the clinician's job is prevention, not judgement. [1] [3]
• Always ask separately about access to firearms and lethal means; never assume none. [6] [7]
• Match the prevention to the evidence and the tier; close the follow-up loop. [4] [8]