UiT Intervention manual and resources

Child Talks: Intervention manual and resources

Version, August 2025AuthorsCharlotte Reedtz, Camilla Lauritzen, Karin van Doesum, Kjersti Bergum Kristensen, Anne-Kari Johnsen and *Karin Källsmyr.RKBU Nord, UiT The Arctic University of Norway and *The organisation «Voksne for barn»Front page drawing: Sofie 9 yearsISBN: 978-82-93031-89-5 (printed version)ISBN: 978-82-93031-90-1 (digital version)

3ContentFOREWORD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5THE IMPORTANCE OF SUPPORTING CHILDREN AND FAMILIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7CHILD TALKS. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 9The aims of Child Talks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9How organize the intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Assessment. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 12Planning the Child Talks intervention. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 13Examples of how to introduce the intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14MEETING 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Overview meeting 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Detailed description of meeting 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Talk about parental mental health and how it affects children. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 18Talk about the care situation for children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Talk about the child’s need for information and follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19MEETING 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Overview meeting 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Detailed description of meeting 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Recommendations for conversations with children of different ages. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 23Tips/examples on how parents can motivate their children. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 24The children may need information about. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Preparations for conversations with the child/children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Tips for parents/caregivers on how to talk to children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

4MEETING 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Overview of meeting 3. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 27Detailed description of meeting 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Tips for conversations with the child. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Specific points for service providers and parents when talking with children. . . . . . . . . . . . . . . . . . . 30MEETING 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Overview of meeting 4. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 33Detailed description of meeting 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Specific issues to discuss for future follow-up. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 34General advice for parents on how to support their children in their everyday life. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35STRATEGIES FOR IMPLEMENTATION AND ORGANIZATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36TRAINING. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 38REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40INTERVENTION LOGBOOK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43RESOURCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Content resources. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 55Resource 1: Family assessment form. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 56Resource 2: Flyer for inviting children to Child Talks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Resource 3: Flyer introducing Child Talks to the parents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58Resource 4: The impact of suicidal behavior of parents on children and how to supportthe children. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 59Resource 5: Factsheet risk and protective factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Resource 6: Screening & Intervention Choices (SIC). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66Resource 7: Evaluation of user satisfaction (to patients/clients/users). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76Resource 8: Suggestions for evaluation (research and quality assurance). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78Resource 9: Other useful resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

5ForewordChild Talks is a preventive intervention aiming to assist professionals in the provision of support to families with parental mental health problems. This includes parents with Mental Illness, Substance use disorders, and families affected by parental Suicide attempts and suicide (MISS). In this manual, parents and other caregivers for the child (e.g., stepparents, foster parents, and other guardians) are also equated, even though the term parents is used in the text. Child Talks can be adopted by mental health workers, social workers, and other professionals who are in contact with families in challenging life situations. Both parents and their children need to receive psychoeducation about parental MISS. This will enable the parents and children to achieve a common understanding of central aspects of parental behaviors and changes related to their condition. Such understanding will make it easier for the family to discuss MISS openly within the family.

6Illustration photo: dotshock / Mostphotos

7Children of parents with Mental Illness, Substance use disorders, and families affected by parental Suicide attempts and suicide (MISS) are at high risk of developing mental health problems in their later lives. About 15 to 23 percent of children live with a parent suffering from mental illness worldwide.1, 2, 3About one-third of these children are facing mental health problems as they grow up. Among this group, one-third is battling with long-term and more serious mental health problems.4, 3Exposure to parental suicide is linked with increased risk for suicide and suicide attempts in youngsters, as well as an increased risk of being diagnosed with a mental disorder. 5, 6, 7, 8, 9, 10, 11 Such exposure also correlates with a lack of school and education completion at all educational levels. 10 Children who lose a parent to suicide may experience profound grief, and the loss can significantly impact their daily lives. This may manifest through changes in the family’s financial situation, increased responsibilities, and shifts in household roles and tasks.10Parental mental illness is also a risk factor for child abuse and neglect, as severe mental illness may significantly reduce a parent’s capacity to take care of his/her child.12, 13, 14These children and adolescents may suffer in silence with problems related to their parents’ MISS. Not surprisingly, their social interactions with other people might be limited due to their parents’ emotional instability and needs. As a result, these children are frequently observed to take a parental role in the family. Furthermore, mental health stigma may create negative feelings, such as shame and guilt, and this makes it hard for the children to talk about their unsettling experiences inside and outside the home.15 Stigma related to mental health and suicide, along with the social isolation of the families concerned, has contributed to ignorance of the needs of this group of children.Suffering from MISS does not mean that the parent is incapable of caring for his/her own children. It is, however, important to acknowledge the negative impact it may have on parental functioning and thereby affect the whole family. Many patients who receive treatment for mental health problems are parents.16. They value their parenting role highly and are in search of support and information about parenting. Similarly, the children concerned also seek support and want to have their questions answered.17When a parent dies by suicide, the family is affected in various ways. The family members may experience a range of different emotions and have many questions that can or cannot be answered. A sudden death may also affect the remaining parents’ parental functioning and capacity to provide care, in a situation where the children are in need of extra attention and care.18 Since bereaved children The importance of supporting children and families

8may experience stigma and isolation related to a parent’s suicide, it is important that these children receive psychoeducation to help them cope and manage their feelings.18, 19 To improve the health and wellbeing of these families, adult mental health services should understand and address the needs of parents and their children. A familyfocused intervention approach can also be beneficial for professionals operating in other fields, such as general practitioners, child and adolescent mental health services, child welfare and protection services, and municipal social services. In order to identify and support the children of parents with a mental illness at an early stage, and to reach children whose parent have attempted or died by suicide, professionals in relevant health, educational and social services need to adopt a family-focused approach.Receiving psychoeducation about the parent’s MISS, understanding the reasons for changes in parental behavior, and talking openly about what the parent is going through is of great importance for the children, as well as for the parents.20, 21, 22, 23 Communication between children and their parents stimulates a problem-solving process and has also proven to be important in terms of building childand family resilience. Illustration photo: Kostiantyn Postumitenko / Mostphotos

9Child Talks is a brief and «light touch» intervention in which healthcare professionals or other service providers talk with the family about the children’s situation and needs. The intervention can be integrated as a part of the treatment for patients who are parents of minor children or may be conducted outside treatment facilities. The main idea is that the intervention should be offered while the parent is receiving treatment for MISS. The intervention Child Talks was originally developed in the Netherlands and has often been part of treatment as usual, offered to all parents with MISS.24 Healthcare professionals can use Child Talks as a framework for communicating with parents and children. The aims of Child Talks• To strengthen the coping skills of the children by providing them with information about their parents’ MISS, as well as by providing emotional and social support. • To make parents aware of children’s experiences and the impact of their MISS on the children. • To strengthen parenting competence by giving the parent(s) advice on how to talk to their children about their and/or the other parents´ MISS. • To identify problems and enable support for the children at an early stage. • To provide the family with advice for further help and support.Child Talks consists of four separate meetings: Two initial meetings with the patient and possibly his/her partner, followed by two meetings with the patient (and the partner), and the children involved. See figure 1 below.Child Talks

10The intervention allows patients who are parents to give a description of their children’s resources and vulnerability, and to participate in the planning of the meetings with their child/children. The parents are provided with the opportunity to express how they want their child/children to be informed about their mental illness and/or life challenges, suicidal attempts, or suicide in the family, as well as how this affects the family situation. During the meetings, the children are invited to answer questions about their understanding and experiences of the family situation, as well as their views on how the situation can be improved. The content of the four separate meetings is described in this manual. Child Talks should be tailored to meet various needs within different families. Figure 1: Overview of the Child Talks meetingsChild Talks• Both parents• Explain purpose• Discuss mental illness, substance use disorder, and suicidal behavior, and how this affects children• Inform parents about aversive outcornes for children• Inform about protective factors• Both parents• Discuss how parents can talk about mental illness, substance use disorder, and suicidal behavior at home• View some examples• Role play, exercises, preparation for talks with children• Prepare parents for challenges that may come up• Plan the meeting with children• Children and parents• Discuss experiences of children• Answer questions• Inform about mental illness, substance use disorder, and suicidal behavior• Parents and children• Evaluation of the meetings• Answer questions• Plan next step• Discuss points of interest for the family and referral to other support optionsMeeting 1 ➡ Meeting 2 ➡ Meeting 3 ➡ Meeting 4

11How to organize the interventionPlanning: Gather relevant information by using, for example, the family assessment form, and tailor the intervention accordingly. Target group: Families with MISS, who have children aged 0 to 18. The intervention may also be feasible for families in complex and challenging life situations (i.e., unemployment, life crises, etc.), given that it is adapted to the family’s needs.Location: The meetings can be arranged in clinics, in local communities, or as home visits.Frequency and duration of the meetings: The meetings can be arranged weekly or biweekly, depending on staff availability and the individual needs of the families. Meetings 1 and 2 are expected to take about 1 hour, meeting 3 (with the whole family) 1 -1,5 hours, and meeting 4 (with the whole family) about 1 hour. Provider of the intervention: Professionals trained in the intervention, mental health workers, social workers, or other service providers.Illustration photo: Taras Grebinets / Mostphotos

12Assessment Professionals can use the Family Assessment Form (see Appendix 1) during or after conversations with patients/clients who are parents of minor children. The questions consist of four categories and are structured as follows:Children of the patients/ parent(s):• How many children (under age 18) do the patient have in the family? • How many children live with the patient? • Children’s name, age, school/day care, siblings, and the names of other caregivers should be recorded.Network:• Where does the child live during the period when the parent is hospitalized? • Who takes care of the child? Does the family have someone who can offer support in a critical situation? • Has the kindergarten, school, public health services or school nurse been informed about the situation? • Are welfare services informed? • Are other institutions involved in the case?• For instance, mental health services for children and the family GP.Needs: • What are the patient’s thoughts about the impact of his/her MISS on the child? • In the case of parental suicide attempts or suicide does the bereaved parent have thoughts on how this had impact on the child? • Does the child have questions related to the family situation or the parent’s mental health problem? If it were the case, what would they like to know about? • Have the parent(s) or other adults observed behavior change in the child? • Is the parent concerned about the child’s situation? Does the parent need assistance from people outside the family? • Are there any friends or relatives in the family’s social circle who can offer support when needed?Information:• What does the child know about the parent’s health condition and life situation? • Does the parent have any preference as to how to inform the child about his/her mental illness and/or life challenges? • What kind of information has been given by the parent? • In the case of parental suicide or attempt: What does the child know about what has happened? • Is the parent willing to give their consent so that the mental health worker or other professionals can talk to the child about the parent’s MISS and give follow-up support? • Has the appointment been made to invite the child to a conversation?

13Planning the Child Talks intervention Introducing Child Talks to the parentsInform parents that it is common practice at the service to ask about the children, and that Child Talks is offered to all parents who have children as part of the routine care. Explain that all healthcare personnel are obligated by law to provide necessary follow-up for children, and that questions about children are not raised because you think they are not doing a good job as a parent, as some parents may fear. The service provider should explain to the parent why Child Talks will be beneficial for the child/children involved. For example: • To avoid misattribution of parent’s behavior to the children themselves (reduce guilt and shame).• To communicate to children that it is ok to talk about their feelings and to ask parents about mental health and other life challenges (reduce taboo and stigma). • To reduce worries (explain children’s need to make sense of their situation and that imagination may be worse than reality). • To provide follow-up support if necessary.Ask parents to describe their child/children, their interests and resources, as well as their challenges. You can use the Family Assessment Form (see resources section) to gather information about the situation of the children if you want. While or after the patient has described their child/children and family, you should offer the Child Talks intervention and provide some information about how the intervention is carried out. Tell them that Child Talks is a good way of talking with their children about matters which many parents find difficult, and that they will be provided with support in the form of planning, structure, content, and evaluation of the talks, as well as support while discussing family matters with the children.In the case of an intentional suicide attempt or in cases where a parent/caregiver has died by suicide, children are often left with little or no information about what happened and how. In our view, the idea of protecting children from the truth about how their parent/caregiver or someone close to them ended their own life is a misconception with aversive consequences for many. Even though it may provoke unpleasant feelings in caregivers and professionals to inform children about suicide, it poses a large burden for children to lack information about what happened and why, and to be left alone with thoughts, fantasies, and worries about this. In addition to this, children in such life circumstances are also confronted with information, questions, and rumors in their social context. Children should be provided with age-appropriate information about why, how, and when parents/caregivers or other close ones committed suicide as soon as possible after it occurred.

14Examples of how to introduce the interventionThere are several ways of introducing Child Talks to parents. Initially, it is often a good idea to explain the various benefits of the intervention for parents. The following sentences are examples of how to approach the family about the situation: • «When a parent is experiencing mental health challenges, it affects the whole family. We therefore talk to all parents about how their children are doing. This is to provide support, and it is not because we think that you are not doing a good job as a parent. We are obligated by law to also attend to children. Tell me about your children…»• «This is no doubt an extremely difficult time for you and your family. What you are going through is likely to have an impact on your children and family life. How do you feel about this situation?» • «We would like to offer you an opportunity to talk with a trained/professional counsellor about parenting and how to support and care for your children in this difficult situation.»• «All patients who are parents of minor children are being offered this service, and it is part of the treatment.» • «We know from experience that this service is helpful for families who are facing tough challenges»

15Illustration photo: Yuri Arcurs / Mostphotos

16Overview meeting 1 Who: With parents, other family members and/or significant others close to the family. Timeframe: 1 hour Content: Use the assessment as a starting point and ensure you have the correct information about the family. Begin by explaining:• The purpose of the conversation. • The goal is to provide support in the parenting role when the family is in a challenging situation. • What can negatively affect children and be challenging for them when a parent is ill (risk factors)? • What is important for the child to cope as well as possible in a demanding situation (protective factors)? Discussion points:• How is the situation affecting the children? • How does the family communicate about the situation? • How do the children express their needs? • What are the most significant challenges in their situation? • What emotions do the parents have in the situation, and what emotions do they think the children have? • Do they get support from their social network? • How can they ask for and receive even more support? Conclude by:• Thanking them for everything they have shared. • Checking if anything is unclear or uncomfortable, and whether the meeting has been helpful. • Explaining a bit about what will happen in the next meeting and agreeing on when and where to meet. • Asking if there is anything the parents would like to discuss further. After the meeting:• Write a log and document in the journal. Meeting1

17Detailed description of meeting 1The content of the first Child Talks meeting is based on the information gathered from the pre-intervention assessment. Ideally, we recommend that both parents/caregivers attend the first meeting if possible. The service provider should inform the parents about the potential consequences of MISS for their children and family life. Furthermore, parents should be provided with relevant information about possible protective factors. Both risk and protective factors related to the parents, children/adolescents, social and physical environments should be discussed (see factsheet in resource section).A careful examination of the resources available for the family can be utilized as a guideline for conversation (see Resource: Screening & Intervention Choices - SIC). For example, how is the communication between parents and children? Do parents have the patience and ability to organize their family life in a satisfactory way? How does the other parent cope with the challenges in the family? How does the other parent compensate for the potential lack of focus and emotional instability of the parent with MISS? Relevant information may include significant others for the child/adolescent, as well as the child’s coping skills and reactions. The SIC can be used as a tool to systematize content during conversations. Utilizing the questions in the form will provide insight into family functioning, the child’s characteristics, and parenting skills. Such insights may assist service providers with the provision of further help and support, and/or referrals to other services.CONTENT OF MEETING 1a. Explain the purpose of the meeting and help the parent(s) to view their mental health problems from a child’s perspective. Give a brief description of the purpose of the meeting. Emphasize that Child Talks is a service aimed to help and support the parent(s) and children in a difficult life situation. Emphasize that is not the purpose of the intervention to assess parents’ ability to raise their own children. Ask parents to describe their children, the current family situation, and the perceived impact the illness, substance abuse, suicide attempt or suicide have on their family and children. Through this process, you will gain a picture of the uncertainties and concerns of the parent(s).b. Discuss MISS with the parents and get a general understanding of the impact of the situation on children and family life.c. Inform the parents about the possible consequences for the children and discuss protective factors. By encouraging the parents to take a child’s perspective, they will gain a deeper understanding of the child’s situation. Focus on the factors that can be improved or changed for the better, conveying hope.d. Summary of the conversation: Briefly summarize your conversation with the parent(s), ask if they have any questions at this point, and introduce the next meeting.

18Talk about parental mental health and how it affects children• Motivate the parents to acknowledge the situation and challenges and reflect on the impact these may have on the family. Encourage parents to pay attention to their children’s descriptions of their experiences and needs when they find themselves in a stressful situation. • In the case of parental suicide attempts or suicide, it is important to be open and honest in communication about suicidal behavior, regardless of the child’s age. This helps clarify any misconceptions about suicidal behavior and events that have occurred and may facilitate the grieving process.• Raise the parents’ awareness about the consequences of letting children take over part of the parenting role or taking too much responsibility in the family. • Address the fact that both the parent(s) and children may experience feelings of guilt and shame. • Discuss the importance of social environment for the children, especially how social isolation can be harmful for them, and how support from family, friends, and neighbors may help them to meet challenges. Photo: Елена Гурова / Mostphotos

19• How is the child’s daily life organized and maintained in terms of structure and routine?• Who is responsible for the practical tasks at home? • If the child has special needs, disabilities or illnesses, which services are provided to secure necessary support and/or assistance to the child and family?• Do other adults take responsibility for any caregiving tasks for the parent with MISS?• Does the child have roles and responsibilities related to the parental MISS at home which should be carried out by adult caregivers?• Does the child receive sufficient support, follow-up, and protection based on their age and development?• Are parents capable of assisting the child with problems and challenges?• How much does the child know and understand about what is happening in the family?• What has the child experienced in relation to parental MISS?• Is the child often sad, angry, worried, anxious, or restless? Are there problems related to the child’s sleeping or eating?• How does the child function in daycare/school (well-being, academic performance, concentration, and attendance)?• Does the child have the energy and opportunity to spend time with friends?• Is the child unusually helpful or suppressing their own needs?• Are parents concerned about their child/children?• Does the child have access to support in the local community (such as from relatives, school, daycare, or at leisure arenas)?• Is there a need for further follow-up beyond what the parents can manage?(Source: The Caregiver’s guide [Pårørendeveilederen], 5.1.)Talk about the child’s need for information and follow-upTalk about the care situation for children

20Overview meeting 2 Who: With parents, other family members and/or significant others close to the family. Timeframe: 1 hour Content: • Begin by checking how they experienced the first conversation. • Explain the purpose of this conversation: to identify challenges in the family and how best to address them.Ask the parents to share and describe:• What might be challenging in the family. • What is difficult about being a parent right now? • What kind of help would they need to become even better in their parenting role? Discuss – and practice, if possible – how they can handle these challenges:• How can they act differently? • How can they communicate in the best possible way with each other and with the children? • How can parents become more aware of what and how they communicate emotions and signals, and instead express these with words? • How can parents make it clear to the children that they are not to blame for or responsible for the situation? • How can parents, specifically, talk to the children about mom’s or dad’s illness/problems? Use the last part of the conversation to plan the next meeting, where the children will be present: • Clarify what the parents want for the next meeting. Is there anything specific that is important to them? • Talk about how to structure the meeting in the best possible way for their situation (number of children, ages, different needs for information). • Do the child/children need a separate meeting beforehand? • How can the parents prepare their children for the meeting so that it feels safe for the children to be open? • Do they want to lead the conversation, or should the staff member do it? • When and where should the meeting take place? Conclude the conversation by:• Thanking them for sharing and contributing. After the meeting:• Write a log and document in the journal. Meeting 2

21CONTENT OF MEETING 2a. Explain the purpose of the meeting: To provide emotional, social and practical support and help parents cope with parenting challenges. These challenges should also form the basis for talking with the children. As mentioned previously, the aim of the conversation is not to question the parents’ ability to care for and raise their own children, but to offer support in a vulnerable life situation. b. Discuss parenting challenges with the parent(s) and focus on those that are most important. The parent(s) should be encouraged to give examples of the challenges they are facing in parenting (i.e. they are unable to engage in the children’s playing, activities or school homework, they struggle to maintain daily routines related to meals, driving the child to sports or other leisure activities, they find it hard to set limits for their children, etc.). Aim to develop an understanding of the challenges related.c. Provide parents with advice and instructions on how to handle the challenges discussed. Role playing, reading short texts from literature, reading interviews or relevant material developed on the topic of being a child with parental MISS can be utilized as the basis for reflections and discussion about parenting challenges and child perspectives. d. Discuss with the parents and reflect on how they can motivate their children to take part in the conversation in the next meeting (see Resource 2). Reflect on what to expect from the next meeting at which the children will participate.e. Discuss how to organize meetings with the child/children, whether parents want to lead or prefer facilitation, and identify key issues or concerns to address.Detailed description of meeting 2The second meeting should also include both parents/caregivers whenever possible. The purpose of the meeting is to provide the parents with advice and instruction on how to discuss MISS with their children (see Appendix 4 for English resources about parental suicide/ suicide attempt). Different approaches, such as role-play, can be adopted. At the end of the meeting, you and the parent(s)/caregiver(s) should prepare for the next meeting together.

22Illustration photo: LightField / Mostphotos

23Recommendations for conversations with children of different ages• Be honest and use simple, age-appropriate language. • Reassure children it is not their fault and that help is available. • Create a safe environment for ongoing discussions, adapting to their evolving needs. • Use activities or casual settings to make conversations more comfortable. Toddlers: Toddlers pick up on their parents’ emotions through facial expressions and tone of voice. They may try to interpret these cues and make choices but often need help managing emotions when they don’t understand the situation. They are sensitive to changes in parental behavior and may blame themselves. It’s important to reassure them using simple language, such as, «I’m not feeling well, but I’m getting help and will get better.» Let them know others are helping you and that it’s not their fault.Children in General: Children are highly observant and may notice changes in their parents’ behavior. They often imagine scenarios worse than reality and may blame themselves for their parents’ struggles. It’s crucial to talk to them about parental mental illness, substance use, or suicide (MISS) to provide clarity and reduce self-blame.Teenagers: Teenagers are likely to have already noticed signs of parental mental health issues or suicidal ideation. Providing them with information about MISS can help them understand the bigger picture. They may worry about stigma, their own mental health, or how their independence might conflict with caregiving responsibilities. Reassure them by discussing the parent’s illness, treatment, prognosis, and available support. Encourage open conversations about their concerns and future plans. Addressing Suicide and Self-Harm: In cases of parental suicide attempts or loss, open communication is essential. Be honest about what’s happening, as children are perceptive and often sense when something is wrong. When discussing suicide or selfharm, use age-appropriate language. Explain that suicidal behavior doesn’t always stem from mental illness and may be linked to other challenges (e.g., financial or housing problems). Self-harm may be a coping mechanism rather than a desire to die. If a family member has died by suicide, be open and honest. Explain the method in simple terms (e.g., hanging stops breathing, overdose stops the heart) to prevent secrecy and foster healing. Service providers can guide parents in choosing the right words to help children process these eventsFor more guidance, see the resource section.

24The children may need information about:The situation of the parent• Balanced and age-appropriate information about parental condition/situation.• Explanation of symptoms, diagnosis, and prognosis.• Causes of parental MISS.• What kind of treatment is provided and its duration.• Which care is provided for the parent.• Consequences of the condition/situation for the parent, the child, and the family.• Opportunities for visits and how such visits will take place.Their own situation• Who will take care of the child.• Who knows about the family’s situation, and who can the child talk to.• What are normal reactions in children when a parent has MISS.• Children are not responsible for helping the parent to recover or for the parent’s behavior.• That it is okay for children to do well and feel happy although the parent is struggling.• It is healthy and beneficial for children to continue with activities they enjoy.26(Source: The Caregiver’s guide [Pårørendeveilederen], 5.1.)Tips/examples on how parents can motivate their childrenProvide the children with context for the conversation. For example: • «I am receiving some help from a place called [name of clinic], and they are inviting the children of parents that are receiving help to come and visit and get some information. The meeting will be for around one hour and [name the people that will participate in the conversation] will participate.»• «The health professionals I get help from are used to talking to children of parents that are receiving help there.» • «The health professionals say that it is helpful for children to come and receive some information and get the opportunity to ask them questions if you want to.»• «I think it will be good for us to talk about our family’s situation with someone who has talked to several other families and knows what may be good for us.»Discuss how the parents would like to organize the meeting with the children. Would they like to take the lead, or do they prefer you to facilitate? Are there any central issues they would like to communicate to their children? Do they have any concerns they would like to discuss in detail?

25Preparations for conversations with the child/childrenPreparing for the conversation with the children can be done together with the parents by answering the following questions in accordance with children’s age:1. What kind of MISS is present?Diagnosis, symptoms, prognosis, and cause.2. Which help is the parent receiving?Treatment and duration. Emphasize that children are never responsible for helping their parents recover. Healthcare professionals are responsible for helping parents to get better.3. Can the child visit the parent?If so, when and how would this take place?4. What are the consequences of the parental MISS?For the family, the parent, and the child.5. What are common reactions in children when parents have MISS?It is important to explain that children react differently, and all reactions are valid. Some children may feel sad, others angry, scared or relieved. Some may not care or may not want to talk or think about it. It’s also common to experience multiple emotions at the same time.6. What will the child’s daily life look like moving forward?Will there be any changes? Emphasize that it is healthy and good for children to engage in activities that make them happy or that they enjoy, even if the parent is struggling. 7. Who can the child talk to about the situation?Who knows about the parental MISS (i.et the other parent, siblings, an aunt, a teacher, or a family friend)? Children should be allowed to talk to others about the situation and not feel burdened by secrecy. It can be helpful if the parent, for example, can say: «It’s completely okay with me if you want to talk to your friends about this.» If only healthcare professionals know about the situation, the child should be provided with the opportunity to reach out if needed.

26Tips for parents/caregivers on how to talk to children• Think about what the child needs to know, what you want to say/not say, and which terms the child will understand.• It is important to explain to children that they are not to blame for the parental MISS, and that you are getting help to get better.• Provide the child with an explanation of the behavior/changes to prevent them from blaming themselves or fantasizing explanations.• Stay calm when talking to the child about parental MISS.• Encourage the child to be open about the illness.• Acknowledge the child’s way of reacting and base the conversation on what the child wants to talk about.• Encourage children to ask questions and share any concerns they may have about parental MISS and its consequences.Illustration photo: Yuri Arcurs / Mostphotos

27Overview of meeting 3 Who: With whole family: parents and/or other important people close to the family and the children. Timeframe: 1.5 hours, but it is important to adjust based on the children’s needs. Content, begin by: • Explaining the purpose of the conversation. • Emphasizing that it is okay for the child to speak openly about the family situation and how they are feeling. The goals are to:• Create a safe space for the child to talk openly about the situation and their needs and wishes. • Understand how the children perceive the situation and what is important for them to cope as well as possible. • Determine what information the children need and want about mom’s or dad’s illness/problems. • Provide the information the children request and answer their questions. • Give the children a sense of recognition and emotional support. If appropriate due to the child’s age and/or the parent’s illness/problems, you may speak with the child alone, with the parents’ consent. If you speak with the children alone, it is important to clarify what should be communicated to the parents from the conversation. Conclude the conversation by: • Thanking them for everything they have shared and checking how they experienced the meeting. • Specifically asking if the children felt safe and if it was okay to be open. • Asking if anything was unclear or uncomfortable, and what they found helpful. • Asking if there is anything they would like to discuss further in the next meeting. • Explaining what will happen next time and agreeing on when and where to meet. After the meeting:• Write a log and document in the journal. Meeting 3

28Detailed description of meeting 3Both parents and their children should be present at the third meeting. One of the main purposes of the discussion is to gain an understanding of how children are coping with the situation. Thus, the children’s experiences of the situation should have full attention. Another key objective of this meeting is to provide the children with information about the parent’s MISS and to offer emotional support. The parent(s) and the professional should clarify that they will answer questions from the children. In some cases, this meeting can be held with the child alone or together with his/her siblings. The presence of the parents is hence optional and depends on the condition of the ill parent and age of the children, among other factors. It is important that the parents give their consent before a professional informs the children about the parental MISS and the family situation. CONTENT OF MEETING 3a. Explain the purpose of the meeting: To provide emotional and social support to both the parents and their children, as well as to strengthen the children’s coping skills by providing them with information about the problems of the parent.b. Develop an understanding of the children’s perspective as to how they experience the situation. c. The child/children should be encouraged to answer questions that involve their situation in kindergarten or school, their relationship with friends and family, and activities outside the home. The professional should get a picture of the child/children’s coping skills, as well as their strengths and resilience. d. Listen to the children’s own stories and encourage them to talk about their feelings of insecurity and doubts. e. In case you have a conversation with a child when the parent/parents is/are absent, the preparation of the feedback to the parent(s) will depend on the age of the child/children. Discuss with the child/children what is important to share with the parent(s), how to share the information and reasons for sharing it.

29Tips for conversations with the childThe following example can be used as an opening sentence for the discussion: «Your parents think it is important that we talk together, they think…» Thereafter you can discuss the points below: • Encourage the children to share their thoughts by saying «what were you thinking about this?» and «what did you do?» Ask them to talk about their feelings by saying «how did that make you feel?»• Give emotional support and pay attention to confusing feelings, such as anxiety, guilt and anger. • Remind the children that they are not alone in this situation and tell them that other children have similar experiences. • Highlight the importance of talking with someone who has knowledge about MISS. • Give information to the children together with the parents or in agreement with the parents (as discussed in the first meeting).• Provide information about parental MISS.• Provide information about potential admission to hospital, the possibility of visiting the parents when they are hospitalized, and what the children can expect from the visits. • Provide information about treatment options, which include talks, medication and therapy.The provision of support through open communication in this meeting will represent a significant experience for many parents and children and will serve as an example of how personal and often stigmatizing issues can be discussed in the family. This experience will make it easier for the family to have follow-up conversations. Keep in mind the following when talking to children:• Acknowledge and validate feelings.• Use simple words and short explanations. Be concrete, calm, and direct.• Explain that children are not responsible for the parents’ MISS, and that they cannot influence their parents’ choice or health.• Talk about inheritance and contagion.• Be honest - children don’t need to know everything, but what is said must be truthful.• Help the child interact with others – talk about how they can respond to questions from others.• Let the child summarize.• Be available afterwards.The Caregiver’s guide [Pårørendeveilederen], 5.1.

30Key points for service providers and parents when talking with children of different agesPoints for service providers to encourage parents/caregivers to discuss with young children • Let your children know when you are not feeling well (e.g., «Daddy is sick, but he is going to the doctor who will help him get better»).• If you feel irritable, reassure your children that it is not their fault (e.g., «Mom/Dad is a little upset, but it has nothing to do with you»).• When talking about your illness or feelings, try to use a calm voice and maintain a gentle expression.• If you are not feeling well and your children are upset, try to manage your own emotions before offering them comfort.• If you find it difficult to meet your children’s needs, seek help and ask someone you trust to be with you while you take a break.• If you need to leave your children for treatment, reassure them that you will return soon or explain how long you will be gone (e.g., «Mommy is not feeling well and needs some help, but I will be back tomorrow»).Points for service providers to highlight for parents/caregivers when talking to children• Avoid keeping mental health issues, substance abuse, and suicide/suicide attempts (MISS) a secret.• Keep the first conversation about parents’/caregivers’ MISS simple and let children know that mental health issues are quite common and do not necessarily prevent people from living a good life.• Encourage children to talk openly about the symptoms they have noticed and ask if they understand the words used to describe MISS.• Provide children with accurate and basic information tailored to their maturity level and need to know.• Create practical plans to help children overcome their fear of discussing what worries them.• Children often find it easier to have a conversation while doing something else. For example, it may be easier for them to ask questions or respond to others’ questions while drawing or playing with modeling clay, beads, or Lego.

31Points for service providers to encourage parents to consider when talking to teenagers • Create an atmosphere that encourages open discussion.• Acknowledge their ways of understanding and interpreting their own reactions and the symptoms and behaviors of adults.• Provide information about MISS, such as symptoms, details about the treatment plan, the treatment the parent/caregiver has received, and what has been helpful for the parent/caregiver.• Offer tips to teenagers on where to find useful information online or from medical institutions.• Both children and teenagers often find it easier to talk about difficult topics while doing something else. For example, starting a conversation in the car or during a walk might be easier.• Be honest while remaining sensitive to their vulnerability regarding mental health issues.• Encourage them to talk about their concerns related to MISS and the potential impact MISS may have on their plans (e.g., moving out of the house).• Discuss different ideas with them and help them create good plans and make sound decisions.• A single conversation is usually not enough, as questions and specific information needs will change over time.Points related to suicide attempts and suicide in the family• Parents/caregivers and service providers should discuss and reflect on how information about this can be presented to children in an age-appropriate way.• Suicide and mental health issues often occur together, but individuals who are suicidal do not necessarily have mental health issues. There may be other underlying causes (e.g., financial problems, housing issues, job loss/unemployment, etc.).• Self-harm is often carried out without the intention of ending one’s life, while at other times, episodes occur in combination with a desire to die. Those who engage in selfharm often explain their actions as a way to relieve unpleasant feelings and gain a sense of control.• Children should be informed about these matters, and professionals can help parents/caregivers choose words that are appropriate for the child’s cognitive and emotional maturity.• For example, explain to children that the parent/caregiver had a desire to die and that the mother/father/sibling or another close person chose to die by hanging, cutting, drowning, overdose, or other means.• Children should be informed that hanging prevents a person from breathing, cutting causes blood loss, drowning leads to water in the lungs and lack of air, overdoses of medication or drugs cause the heart to stop beating, and such actions result in death.• Openness and honesty about these matters can be very difficult, but secrecy about what actually happened will negatively impact the grieving process and communication within the family.

32Illustration photo: LightField / Mostphotos

33Overview of meeting 4 Who: With parents and/or other important people in or close to the family and the children. Timeframe: 1 hour, but it is important to adjust based on the children’s needs. Content, begin by: • Checking how the children and parents experienced the previous meeting. Explain that in this meeting, we will: • Allow everyone to ask any questions they have. • Explore if there is anything the children think could be different or better. • Determine how things can be made different or better. • Identify what the parents need to function as well as possible in their parenting role and how they can receive that support. • Plan how the family can continue working on communicating well and openly about challenges and needs. • Assess whether there is a need to involve local services or resources. Conclude the conversation by: • Thanking everyone for sharing and contributing. • Asking each person to share something they are taking away from the meeting and what they found helpful. • Ensuring no one is left with anything they wish they had discussed. Finally: • Ask the parents to fill out an evaluation form (example in the manual’s list of resources). After the meeting:• Write a log and document in the journal. Meeting 4

34Detailed description of meeting 4Key topics to address for future follow-up The fourth and last meeting should also include both parents/caregivers and their children. The purpose of this meeting is to sum up and evaluate the previous meetings. All questions from the family should be addressed at this stage and plans for followup should be made. The service provider should assist the family in seeking additional support if necessary. In this meeting, the parents and children should be provided with the opportunity to share their views, and hopefully the parents are better equipped to take the perspective of the child/children and thereby to meet the needs of their children.• Talk to the family about their extended family/friends and social network and detect if there are people in their network that they can get help or extra support from in any way. Be specific. • Motivate children to join coping groups for children if available. • Provide information about other types of services that are available. • Provide information about digital resources that can be relevant for the family.• Provide information about services offered by other institutions and communities if necessary (i.e. public health care centers and child welfare and protection services). CONTENT OF MEETING 4a. Explain the purpose of the meeting; identify the problems faced by the children and provide the family with support and adequate assistance. b. Raise central issues from previous meetings and give feedback to parents and children. c. Provide parents and children with the opportunity to ask questions. d. Discuss the prospect of the family situation, and main areas the family should focus on. e. If you are doing an evaluation for quality assurance in your service now is a good time to ask parents to fill in an evaluation form to monitor quality aspects of the intervention.f. Summarize the meeting and any agreements that were made. Provide children and parents with the opportunity to reach out to you if they have more questions or need support.

35Practical advice for parents on supporting their children in daily life• Provide predictability and security by letting the child know what is happening.• Maintain daily routines if possible.• Be available, open, and inclusive.• Try to see and understand the situation through the child’s eyes.• Don’t pressure the child to talk.• Prioritize quality time together with the child.• Acknowledge different reactions among siblings.• Encourage and create opportunities for the child to spend positive time with friends.• Seek support from other adults if needed. The Caregiver’s guide [Pårørendeveilederen], 5.1.Illustrastion photo: Anne Muscat Scerri / Mostphotos

36Strategies for implementation and organization Child Talks is a brief intervention that can be added and integrated into existing practice. The intervention can be implemented in different settings, such as mental health clinics (inpatient and outpatient), community mental health services, centers of general practitioners, health services at schools and daycare centers, child welfare and protection services as well as other health and/or care services providing treatments/support/follow-up for patients with MISS and/or their family. Additionally, the local communities may have crisis teams or a psychosocial emergency service which offers urgent assistance to individuals who are in challenging life situations such as exposure to violence, suicide or suicide attempts or other crises. To safeguard children in families experiencing MISS or other crises, Child Talks may be utilized. The intervention is flexible and can be adopted and implemented in various ways, depending on the context and the availability of practical options. Below we outline three different approaches to adaptation. Option 1: Child Talks teams within the treatment facility Child Talks can be included in existing service provision (i.e., hospital, wards, treatment centers) by the establishment of special teams or individuals. Such teams may constitute personnel who are responsible for implementing the intervention and providing the service. The team should consist of at least one «champion», a term that refers to professionals who play a central part in speeding up the implementation process27,28. The champions should be personnel who have obtained in-depth knowledge of the Child Talks, who are highly motivated, and who can engage the rest of the team28. The champions should be capable of identifying the problems that may lead to barriers and delays during the process and provide solutions accordingly29.Option 2: Child Talks provided by the principal service provider Therapists or service providers who are the principal service providers for patients may also be trained to implement the intervention on their own. In such cases, the Child Talks meetings will be organized and provided by individual service providers within the treatment/service facility and integrated as part of treatment/service as usual for relevant patients/clients/users. Option 3: Child Talks provided by professionals in the local community Child Talks may also be implemented in services in the community, such as municipal mental health clinics (inpatient and outpatient), community mental health services, centers of general practitioners, health services at schools and daycare centers, child welfare and protection services as well as other community health and/or care services providing treatments/support/followup for patients/clients/users with MISS and/or their family. This strategy calls for a functional collaboration between the principal service provider and the providers of the intervention

37within a secondary service provider. It should be kept in mind that in such cases, the providers of Child Talks may have limited insight into the parents’ diagnosis, life situation, as well as the challenges they are facing. Important factors for successful implementation The term implementation is commonly referred to as a process of putting a defined action into effect, in this case, the Child Talks intervention. There are several factors that matter in order to successfully implement a new practice or intervention. First, one must make sure that key aspects of the intervention are covered and that a plan has been made to adapt the intervention to the local context. The management needs to be on board during the implementation process and should take a realistic view of the time and resources required in carrying out the intervention. The organization must focus on human resource processes, such as recruitment, selection of candidates, hiring, and training. Creating readiness for organizational change within the workforce is a key prerequisite for a successful implementation process. Central to creating readiness for change is skills training and developing knowledge within the workforce. It is also crucial to evaluate the implementation process continuously, so that adaptations and adjustments can be made to ensure high-quality service provision. Illustration photo: Yuri Arcurs / Mostphotos

38In Norway the training in the intervention is provided by Voksne for Barn.. Please contact [email protected] if interested. For information about international training, please contact RKBU North, UiT-The Artic University of Norway, Tromsø: Karin van Doesum; [email protected], Charlotte Reedtz: [email protected] Camilla Lauritzen: [email protected] Training Illustration photo: Goodboy Picture Company / istockphoto

39Illustration photo: Mikhail Kokhanchikov / Mostphotos

401. Havinga, P. J., Boschloo, L., Bloemen, A. J. P., Nauta, M. H., De Vries, S. O., Penninx, B. W. J. H., … Hartman, C. A. (2017). Doomed for disorder? High incidence of mood and anxiety disorders in offspring of depressed and anxious patients: A prospective cohort study. Journal of Clinical Psychiatry, 78(1), e8–e17. https://doi.org/10.4088/JCP.15m099362. Leijdesdorff, S., Van Doesum, K., Popma, A., Klaassen, R., & Van Amelsvoort, T. (2017). Prevalence of psychopathology in children of parents with mental illness and/or addiction: an up to date narrative review. CE: Alpana; YCO, 300412(4), 312–317. https://doi.org/10.1097/YCO.00000000000003413. Reupert, A., & Maybery, D. (2016). What do we know about families where parents have a mental illness ? A systematic review. Child & Youth Services, 37(2), 98–111. https://doi.org/10.1080/0145935X.2016.11040374. Brockington, I., Chandra, P., Dubowitz, H., Jones, D., Moussa, S., Nakku, J., & Quadros Ferre, I. (2011). WPA guidance on the protection and promotion of mental health in children of persons with severe mental disorders. World Psychiatry, 10(2), 93–102. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3104877&tool=pmcentrez&rendertype=abstract5. Burrell, L. V., Mehlum, L., & Qin, P. (2017). Risk factors for suicide in offspring bereaved by sudden parental death from external causes. Journal of Affective Disorders, 222(March), 71–78. https://doi.org/10.1016/j.jad.2017.06.0646. Calderaro, M., Baethge, C., Bermpohl, F., Gutwinski, S., Schouler-Ocak, M., & Henssler, J. (2022). Offspring’s risk for suicidal behaviour in relation to parental death by suicide: Systematic review and meta-analysis and a model for familial transmission of suicide. British Journal of Psychiatry, 220(3), 121–129. https://doi.org/10.1192/bjp.2021.1587. Garssen, J., Deerenberg, I., MacKenbach, J. P., Kerkhof, A., & Kunst, A. E. (2011). Familial risk of early suicide: Variations by age and sex of children and parents. Suicide and LifeThreatening Behavior, 41(6), 585–593. https://doi.org/10.1111/j.1943-278X.2011.00050.x8. Geulayov, G., Metcalfe, C., Heron, J., Kidger, J., & Gunnell, D. (2014). Parental suicide attempt and offspring self-harm and suicidal thoughts: Results from the Avon longitudinal study of parents and children (ALSPAC) birth cohort. Journal of the American Academy of Child and Adolescent Psychiatry, 53(5), 509-517.e2. https://doi.org/10.1016/j.jaac.2013.12.0229. Niederkrotenthaler, T., Floderus, B., Alexanderson, K., Rasmussen, F., & Mittendorfer-Rutz, E. (2012). Exposure to parental mortality and markers of morbidity, and the risks of attempted and completed suicide in offspring: An analysis of sensitive life periods. Journal of Epidemiology and Community Health, 66(3), 233–239. https://doi.org/10.1136/jech.2010.10959510. Burrell, L. V. (2021). Psykososiale vansker etter tap av foreldre i barndom og ungdomstid (Psychosocial difficulties following the loss of parents in childhood and adolescence). Suicidologi, 26(3), 4–25. https://doi.org/10.5617/suicidologi.932111. Burrell, L. V., Mehlum, L., & Qin, P. (2022). Parental death by external causes during childhood and risk of psychiatric disorders in bereaved offspring. Child and Adolescent Mental Health, 27(2), 122–130. https://doi.org/10.1111/camh.12470References

4112. Goodman, S. H., & Gotlib, I. H. (1999). Risk for Psychopathology in the Children of Depressed Mothers : A Developmental Model for Understanding Mechanisms of Transmission. Psychological Review, 106(3), 458–490.13. Hosman, C. M., van Doesum, K. T., & van Santvoort, F. (2009). Prevention of emotional problems and psychiatric risks in children of parents with a mental illness in the Netherlands: I. The scientific basis to a comprehensive approach. Advances in Mental Health, 8(3), 250–263. https://doi.org/10.5172/jamh.8.3.25014. Reedtz, C., Lauritzen, C., & Van Doesum, K. T. M. (2012). Evaluating workforce developments to support children of mentally ill parents: Implementing new interventions in the adult mental healthcare in Northern Norway. BMJ Open, 2(3). https://doi.org/10.1136/bmjopen-2011-00070915. Mordoch, E., & Hall, W. A. (2002). Children living with a parent who has a mental illness: A critical analysis of the literature and research implications. Archives of Psychiatric Nursing, 16(5), 208–216. https://doi.org/10.1053/apnu.2002.3623116. Reedtz, C., Lauritzen, C., Stover, Y. V., Freili, J. L., & Rognmo, K. (2019). Identification of children of parents with mental illness: A necessity to provide relevant support. Frontiers in Psychiatry, 9(JAN). https://doi.org/10.3389/fpsyt.2018.0072817. Grove, C., Riebschleger, J., Bosch, A., Cavanaugh, D., & van der Ende, P. C. (2017). Expert views of children’s knowledge needs regarding parental mental illness. Children and Youth Services Review, 79. https://doi.org/10.1016/j.childyouth.2017.06.02618. Costa, A. V, Mendes, S., Pires, A. S., Melo, S., Borges, S., Jorge, J., & Mendes, G. (2020). Growing in the shadows of Suicide. Nascer e Crescer, 29(2), 101–107. https://doi.org/10.25753/BirthGrowthMJ.v29.i2.1863119. Schreiber, J. K., Sands, D. C., & Jordan, J. R. (2017). The Perceived Experience of Children Bereaved by Parental Suicide. Omega (United States), 75(2), 184–206. https://doi.org/10.1177/003022281561229720. Goodyear, M., Maybery, D., Reupert, A., Allchin, R., Fraser, C., Fernbacher, S., & Cuff, R. (2017). Thinking families: A study of the characteristics of the workforce that delivers family-focussed practice. International Journal of Mental Health Nursing, 26(3), 238–248. https://doi.org/10.1111/inm.1229321. Foster, K., Maybery, D., Reupert, A., Gladstone, B., Grant, A., Ruud, T., … Family-focused, N. K. (2016). Child & Youth Services Familyfocused practice in mental health care : An integrative review Family-focused practice in mental health care : An. Child & Youth Services, 2298(April), 129–155. https://doi.org/10.1080/0145935X.2016.110404822. Beardslee, W. R., Wright, E. J., Gladstone, T. R. G., & Forbes, P. (2007). Long-term effects from a randomized trial of two public health preventive interventions for parental depression. Journal of Family Psychology : JFP : Journal of the Division of Family Psychology of the American Psychological Association (Division 43), 21(4), 703–713. https://doi.org/10.1037/0893-3200.21.4.70323. Solantaus, T., Paavonen, E. J., Toikka, S., & Punamäki, R. L. (2010). Preventive interventions in families with parental depression: children’s psychosocial symptoms and prosocial behaviour. European Child & Adolescent Psychiatry, 19(12), 883–892. https://doi.org/10.1007/s00787-010-0135-324. Van Doesum, K., & Koster, C. (2008). KOPP Praten met ouders kinderen: Handleiding preventieve huisbezoeken voor ouders met psychiatrische problemen en hun kinderen Talking with parents and Children: Manual Child Talks for families with parents who has mental health problems). Deventer, the Netherlands25. Raundalen, M. (2016). Hva skal vi si til barn om selvmord? Suicidologi, 21(1), 4–9. https://doi.org/10.5617/suicidologi.2900

4226. Van Schoors, M., Van Lierde, E., Steeman, K., Verhofstadt, L. L., & Lemmens, G. M. D. (2023). Protective factors enhancing resilience in children of parents with a mental illness: a systematic review. Frontiers in Psychology, 14(December), 1–10. https://doi.org/10.3389/fpsyg.2023.124378427. Soo, S., Berta, W., & Baker, G. R. (2009). Role of Champions in the Practice Change. Healthcare Quarterly, 12, 123–128. https://doi.org/10.12927/hcq.2009.2097928. Meyers, D. C., Durlak, J. A., & Wandersman, A. (2012). The Quality Implementation Framework: A Synthesis of Critical Steps in the Implementation Process. American Journal of Community Psychology, 50(3–4), 462–480. https://doi.org/10.1007/s10464-012-9522-x29. Lauritzen, C., & Reedtz, C. (2013). Support for children of mental health service users in Norway. Mental Health Practice, 16, 12–18. https://doi.org/10.7748/mhp2013.07.16.10.12.e875Illustration photo: Illia Bondar / Mostphotos

Intervention Logbook

45Intervention LogbookThis logbook can be used to take minutes during and/or after each meeting. Depending on the routines in your organization how to record the meetings with the family, a brief summary of the meetings can be kept in the patient’s health (medical) record. At the end of the fourth meeting you can ask the parent/patient to complete a questionnaire on user satisfaction (see resource section). Illustration photo: Yuri Arcurs / Mostphotos

46Meeting 1Date: Duration: Location:Name of the service provider who conducts the Child TalksParticipants: Patient:Partner:What topics and concerns were discussed in the meeting?––––What kind of supports that are available to the family in and outside the household? Do the parents have concerns regarding the children? Details (if any):Next appointment

47Meeting 2Date: Duration: Location:Participants: Patient:Partner:What topics and concerns were discussed in the meeting?––––What challenges did the parents mention in the meeting? How were the challenges discussed? (conversation / role play)Which concerns (if any) did the parents have for their children?What kind of expectations do the parents have for the next meeting in which the whole family would be present? Details (if any):Next appointment

48Illustration photo: User_72780 / Mostphotos

49Meeting 3Date: Duration: Location:Participants: Patient:Partner:Child(ren):Others:What topics and concerns were discussed in the meeting?––––What kind of supports that are available to the family in and outside the household?What concerns did parents and children describe? Details (if any):Next appointment

50Meeting 4Date: Duration: Location:Participants: Patient:Partner:Child(ren):Other:What topics and concerns were discussed in the meeting?What aspects of the family life/situation should members of the family work with now?What follow-up arrangements were made?Which activities do the children wish to participate in? Which advice was given to the children on how to seek additional support?