Family assessment and family interventions — formative SAQs

SAQ 1 — Assessment, mechanism and choosing the rung (10 marks)

An 8-year-old boy with established ADHD continues to display escalating aggression at home despite an optimised stimulant. His mother, raising him alone after a recent separation, is exhausted and reports that nothing she tries works for more than a few days. The school reports worsening playground conflict. There is no disclosure of violence or maltreatment. [6] [12]

Questions

1. Outline the components of a systematic, non-blaming family assessment in this case, including the genogram and a validated family-functioning approach. (3 marks) [10]
2. Name the family-level mechanism most likely maintaining the behaviour and explain how it works. (3 marks) [6]
3. State the first-line family intervention for this presentation, justify why it precedes family therapy, and cite the evidence. (4 marks) [4] [7]

Model answer

Assessment (3). A three-generation genogram, drawn with the mother, maps structure, the recent separation, losses and any repeating patterns of conflict. Add a validated family-functioning measure — the McMaster Family Assessment Device dimensions (problem-solving, communication, roles, affective responsiveness and involvement, behaviour control) or the Family APGAR — and observe the mother-child relationship in a naturalistic moment. Gather the school's view alongside the mother's and build a shared, non-blaming formulation that names the problem to work on together. The framing is critical: the mother is not failing, the interaction is being shaped by its consequences. [10]

Mechanism (3). The coercive cycle, described by Patterson, is most likely. The child behaves aversively — demanding, hitting, refusing — and the mother, exhausted, reacts harshly or gives in. Either reaction ends the aversiveness in the short term, which negatively reinforces the behaviour, so it escalates over months. Single parenthood and recent separation are not the cause; the coerced interaction loop is. [6]

First-line intervention (4). Behavioural parent training is first-line — not family therapy — because it targets the coercive cycle directly by changing what the parent does. Named options include parent management training (Kazdin), the higher levels of Triple P, the Incredible Years, and Parent-Child Interaction Therapy, whose meta-analysis shows large effects on child behaviour and parenting. Escalation to Functional Family Therapy or Multisystemic Therapy is reserved for persistent or severe cases, because jumping straight to family therapy overshoots, drops out, and wastes resources. The family intervention is adjunctive to continuing the child's ADHD treatment on its own merits. [4] [6] [7]

SAQ 2 — Structured family therapy, anorexia and the safety conversion (10 marks)

A 14-year-old girl with anorexia nervosa has been medically stabilised after an admission for refeeding. Her parents, who argue intensely about who is "to blame," are keen for individual therapy "so she can sort herself out." During the assessment you learn that the father's critical comments about her eating dominate every meal, and the mother quietly discloses that the parents' own relationship involves ongoing verbal abuse. [9]

Questions

1. Cite the evidence that family-based treatment is first-line for adolescent anorexia, and explain what family-level mechanism it targets. (3 marks) [9]
2. Explain why the parental conflict and the father's critical mealtime tone matter for prognosis, naming the construct. (3 marks) [9]
3. How does the disclosed verbal abuse change your plan, and what is the disposition? (4 marks) [9]

Model answer

Evidence and mechanism (3). In the Lock randomised clinical trial comparing Family-Based Treatment with adolescent-focused individual therapy for adolescent anorexia, FBT was the superior approach. The family-level mechanism it targets is expressed emotion — the critical, hostile and over-involved tone that predicts relapse in eating disorders, early psychosis and mood disorders. FBT works partly by lowering that tone through structured parental empowerment in refeeding, which is why the parents' request for "individual therapy so she can sort herself out" misreads the evidence. [9]

Prognosis and the construct (3). The father's critical comments about her eating are high expressed emotion, which predicts relapse in anorexia; the intense parental conflict over blame adds chronic stress load, the third named mechanism, which impairs recovery from any illness. A family can love a child intensely and still carry a tone that undermines recovery, so the prognosis here is guarded unless the family work addresses the tone and the conflict. [9]

Safety conversion and disposition (4). The disclosed ongoing verbal abuse is intimate-partner violence, and it converts part of the plan to a safeguarding and safety pathway. I screen the mother alone, make a same-day safety plan, and involve child-protection and domestic-violence services where thresholds are met. Joint family sessions are contraindicated while violence is active, because they can endanger the mother and the child; however, the eating-disorder family work (FBT) can proceed with the non-offending structure once safety is established. I name the clinician who owns the plan, the follow-up date, and the return precautions, and coordinate with the GP, school and mental-health team — never an open-loop referral that leaves a vulnerable family exposed. [9]