Family assessment and family interventions — branching viva

Stem

The examiner opens with a child whose presentation is not settling, then escalates through family assessment, the mechanisms, intervention selection, the evidence, a pharmacotherapy trap, and a safeguarding twist. [6] [12]

Branch 1 — Assessment and the mechanism

Examiner: An 8-year-old with ADHD keeps escalating his aggression despite an optimised stimulant. His mother is exhausted; nothing works for long. How do you assess the family? [10]

Strong answer: I draw a three-generation genogram with the mother to map structure, the recent separation and any repeating patterns; I add a validated family-functioning measure such as the McMaster Family Assessment Device or the Family APGAR; and I observe the mother-child relationship in a naturalistic moment rather than staging one. I gather the school's view alongside the mother's and build a shared, non-blaming formulation that names the problem to work on together. [10]

Examiner: What family-level mechanism is most likely maintaining this? [6]

Strong answer: The coercive cycle, described by Patterson. The child behaves aversively, the exhausted mother reacts harshly or gives in, and either reaction ends the aversiveness in the short term — which negatively reinforces the behaviour, so it escalates over months. The mother is not failing; the interaction is being shaped by its consequences. [6]

Branch 2 — Choosing the intervention rung

Examiner: First-line family intervention for this boy? [4]

Strong answer: Behavioural parent training, not family therapy — because it targets the coercive cycle directly by changing what the parent does. The named options are parent management training, 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. I would escalate to Functional Family Therapy or Multisystemic Therapy only if the presentation were persistent or severe. [4] [6] [7]

Examiner: Why not family therapy first? [6]

Strong answer: Because a simple disruptive-behaviour problem overshoots at the family-therapy rung — it drops out, wastes resources, and delays the first-line evidence. Family therapy is reserved for adolescent conduct, substance use and anorexia, where the family-as-patient models (FFT, BSFT, FBT) have their specific evidence. [6] [9]

Branch 3 — Evidence and the anorexia case

Examiner: A 14-year-old with anorexia, just stabilised. Parents ask for individual therapy. Your evidence? [9]

Strong answer: I would offer Family-Based Treatment, the Maudsley model. In the Lock randomised clinical trial comparing FBT with adolescent-focused individual therapy for adolescent anorexia, FBT was superior — family therapy is first-line here, not adjunctive. The mechanism it targets is expressed emotion: the critical, hostile, over-involved family tone that predicts relapse. The parents' request for individual therapy misreads the evidence. [9]

Examiner: What does FBT actually get the parents to do? [9]

Strong answer: It empowers the parents to take charge of refeeding through a structured, phased approach — initially full parental management of eating, then a gradual hand-back of eating and autonomy to the adolescent as weight and health restore. The active ingredient is lowering the expressed-emotion tone by giving the parents a clear, non-blaming role in recovery. [9]

Branch 4 — Multisystem care and the trap

Examiner: When do you reach for Multisystemic Therapy? [1]

Strong answer: For severe, chronic or entrenched presentations — violent and chronic juvenile offending where parent training and family therapy have not sufficed. Henggeler's landmark trial showed MST with violent and chronic juvenile offenders reduced re-arrest and out-of-home placement versus usual services. MST wraps services around the family, school, peer group and community; residential or out-of-home placement is the last resort, not the default. [1]

Examiner: A colleague suggests a trial of an SSRI "to help the mother tolerate the behaviour." [6]

Strong answer: I would not conflate treating a parental mood disorder with a family intervention. If the mother has a diagnosable depression, that is treated on its own merits by her own clinician — but an SSRI is not a family intervention, and the coercive cycle is addressed by parent training, not by medication. I would also be careful that suggesting an SSRI "so she can tolerate" the behaviour does not locate the problem in the mother. [6]

Branch 5 — Safeguarding conversion

Examiner: During the anorexia assessment the mother quietly discloses that the father's verbal abuse of her is ongoing. [9]

Strong answer: I stop and convert 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 the violence is active, because they can endanger the mother and the child. The eating-disorder family work can proceed with the non-offending structure once safety is established. I name the owner, the follow-up and the return precautions, and coordinate with the GP, school and mental-health team — never an open-loop referral. [9]

Examiner scoring cues

• Uses a genogram plus a family-functioning measure and dyad observation, and builds a non-blaming shared formulation. [10]
• Names the correct mechanism — coercive cycle, expressed emotion, or chronic stress load — and matches the intervention to it. [6]
• Defends parent training as first-line for disruptive behaviour and cites the evidence (Triple P, PCIT, PMT). [4] [7]
• Defends FBT as first-line for adolescent anorexia and names expressed emotion. [9]
• Names MST for severe/chronic offending and cites Henggeler. [1]
• Converts to safeguarding the moment family violence surfaces, and never blames the parents or leaves an open-loop referral. [9] [12]