51Which advice on how to seek further support and assistance were provided to the parents? Were the children referred to Child Mental Health Services or other services? Name of the child/adolescent:In what way will the family followed-up by the professional responsible for the patient? Other comments:Details (if any): Which questionnaires/recources are utilized by the professional and/or parents?Describe:
52Illustration photo: Yuri Arcurs / Mostphotos
53Resources
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55Content resources1. Family assessment form .............................................................................................................................................................................................................................562. Flyer for inviting children to Child Talks ........................................................................................................................................................................573. Flyer introducing Child Talks to the parents .......................................................................................................................................................584. The impact of suicidal behavior of parents on children and how to support the children 595. Factsheet risk and protective factors ..............................................................................................................................................................................646. Screening & Intervention Choices (SIC) ..........................................................................................................................................................................667. Evaluation of user satisfaction (to patients/clients/users) ...........................................................................................................768. Suggestions for evaluation (research and quality assurance) ...............................................................................................789. Other useful resources .................................................................................................................................................................................................................................82
56The assessment of children (0–18 år)of parents receiving mental health treatmentFill in the form for each child and keep it in the patient’s journalThe patient’s name and identification numberDiagnosis of the patient/parentName of the child:Date of birth:Address:Phone:Siblings: names and ageWith whom does the child live?- Who has the parental responsibility/ child custody?- Contact arrangements with the other parent?Are there other people living in the household?(e.g. grandparents, step-parents etc.)?Who takes care of the child when you are admitted to hospital/receiving treatment?Does the child receive care and support from other adults? (E.g. relatives, neighbors, friends etc.)Does the child go to school, daycare or kindergarten?(Please choose the alternative that applies to your child.)Does the child know that you or your partner have a mental illness, have committed or attempted suicide, and or are/have been admitted to the hospital?Has the child received information about the parent’s mental illness, health condition, suicide or suicide attempt?Are you concerned about your child?Has the child been in contact with other services? (E.g. the CPS, CAMHS, public health nurse etc.)Do you need support and assistance from other services in addressing your concerns about your child? Is there more information we need to know about the family and the child? Resource 1: Family assessment formHostpital:Date:Filled in by:Marrital status:Number of children:Are you expecting a child?
57Invitation to children and adolescent to participate in a meeting Hi!All children and adolescents who have a parent who are getting some help or treatment from our service are invited to come and talk with to the people working here. We have a responsibility to check in on how the children are doing.Many children are in a similar situation as you. We know it can be helpful for children to get some information, and some children want to ask us questions about their parent’s health or situation. If you don’t want to share anything or talk in the meeting, that’s completely fine. We would still love to have you join us. The meeting will be at [fill in site/ room] on [fill in date and time depending on the child’s age] and will last for approximately one hour. [fill in names of the people who will participate] will participate. If you have any questions, you can call me at: [provide phone number and optionally a picture if the professional who will partake in the conversation]Look forward to seeing you!Resource 2: Flyer for inviting children to Child Talks
58How are the children doing now?Informative Conversations with Parents and ChildrenWhen a parent is dealing with mental illness, substance use disorders, or families are affected by parental suicide attempts and suicide (MISS), it can be confusing or even scary for children. That’s why our prevention team is here to support both you and your child(ren) during this difficult time.Children react in different ways to these situations, depending on their age and personality. While some may seem to be coping well, this can be misleading. Out of love and concern, many children keep their worries and questions to themselves, not wanting to trouble their parent(s). To help prevent future emotional problems and to give children a safe space to talk, [-name organization-] offers family conversations.These family conversations focus on what’s going on at home and give your child the chance to share their thoughts and feelings. Our aim is to support your family and help you talk openly with your children. We’re not here to judge or check up on your parenting.Extra help and support are very important right now, and family and friends can play a big role too. [-Name organization-] hopes to be part of that support.How It WorksA professional from [-name organization-] will first contact you by phone to schedule an appointment. During the session, we will provide helpful information and speak with you and your children. You’ll also have the chance to ask any questions you may have.Of course, we explain everything to your children in a way that suits their age and understanding. We’ll also give you practical tips to use in daily life, as well as informative brochures for both you and your child(ren), so you can look at them together whenever it feels right.More Information and How to RegisterIf you are currently receiving services at [Service provider], you can ask your service provider to arrange these family conversations for you.If you are not receiving services at [Service provider], please contact [organization] directly for more information or to sign up.Name organization:e-post, website and telephone numberResource 3: Flyer introducing Child Talks to the parents
59What do the children experience in case of parental suicide or suicide attempt?Comparable Experiences to COPMI:Children of parents with suicidal behavior experience emotions similar to those of children of parents with mental illness (COPMI), such as fear, sadness, guilt, shame, stigmatization, and parentification. These emotions may be felt more intensely or differently due to the suicidal behavior. The experiences vary depending on the child’s age and developmental stage.1, 2Abandonment:• Children may feel abandoned and struggle with why their relationship with the deceased wasn’t enough to prevent the suicide. They may feel left behind by the person they needed most for their basic needs.• Children might feel guilty about experiencing relief, which is a normal part of the grieving process.• Understanding of death evolves with age: around 6 years old, children grasp the finality of death, and by 9, they understand how and why someone dies.• Grief can manifest in various ways, such as behavioral changes, physical symptoms, play, hyperactivity, anxiety, and sleep problems. 3, 4, 5Anger:Anger is common among survivors, including children, who may direct it at the deceased for not seeking help, at others for not preventing the suicide, or at themselves for feeling anger despite knowing their loved one suffered.2, 4, 6Relief:• Children may feel relief that their parent’s suffering is over or that life at home was stressful before the suicide.7• Example: Annabel, 10 years old, expressed relief that her father was freed from his suffering through suicide.Grief:Children will experience grief after losing a parent, regardless of the cause of death. They are resilient and can process their loss by grieving in small bursts, alternating between crying and playing. The grieving process depends on factors such as age, personality, and the cause of death.6, 8What helps the children, and how can you, as a professional, contribute to thisOpen CommunicationOpen and honest communication about suicidal behavior is recommended regardless of the child’s age. It helps clarify any misconceptions about suicidal behavior and events that have occurred and can facilitate the grieving process. Misleading or avoidant communication is a risk factor for developing later issues, such as prolonged grief or psychiatric problems.9, 10Resource 4: The impact of suicidal behavior of parents on children and how to support the children Source: Part of Factsheet Trimbos institute «Parental Suicide or suicide attempts» 2023
60Explanation• Communication should be adapted to the child’s age, temperament, and cognitive ability.10• Without an explanation, children will fill in the gaps with their imagination, which is often worse than reality and can lead to confusion. Confusion and secrecy can cause children to no longer trust their own perceptions.9, 10• If suicidal behavior is explained as the result of various stressors, children may see this as a realistic solution to problems.10• Secrecy around suicidal behavior is linked to the perpetuation of stigmas surrounding it.11Making senseAfter a suicide, children may spend a lot of time wondering why their parent took their own life and who is to blame. In this way, the child tries to make sense of the suicide. This process can lead to feelings of guilt, shame, rejection, and abandonment. Psychoeducation about suicidality and grief supports the process of making sense.11, 12• Be honest: Children are perceptive and often sense that something is wrong. Delaying the truth does not make the situation any less severe and can damage the child’s trust.• Reassure them: Children may sometimes feel as if their sadness will never go away. It’s important to tell them that it will lessen over time.6• Use clear language: Euphemisms like «sleeping forever» or «unable to continue living» often raise more questions. Use straightforward language such as «Daddy is dead because he jumped off a building» or «Mommy tried to hang herself because she wanted to die.» Tailor the amount of detail to the child’s age.• Explain it’s not a solution: Explain to children that suicide is never a solution to problems, and they should never attempt it. Discuss any questions or fears they may have, such as whether the other parent might do the same or if they might feel that way themselves. Take these concerns seriously.• Answer questions: Children often have many questions. Try to answer them as best as you can. It’s also okay to admit when you don’t know the answer.• Don’t overload them: Children typically don’t ask for more than they can handle at that moment. Adjust the information you provide to match the child’s needs.• Choose the right moment: While there is no perfect time, some degree of stability is desirable.• Create a safe space: It is important to create a safe environment where children feel comfortable.
61Explanation• By identifying internal vulnerabilities and external stressors, an answer can be sought to the question: what was the cause of the suicide? In this way, no one is blamed.12• Making sense of family experiences helps children understand and provides space for their own grief reactions.12• Psychoeducation about suicidal behavior: Suicidality is complex and particularly difficult for children to understand. Try to provide children with a definition of suicidality. Explain that the suicide was a result of something like depression and that this is not the same as just feeling down. Emphasize that it is not a solution to problems and that there is always another choice.• Psychoeducation about grief: Explain that grieving means missing someone you loved very much and that all the emotions that come with it are normal. Common feelings include sadness, guilt, shame, fear, anger, and relief.8, 9• Emphasize to children that the suicide was not their fault.• Dealing with a parent’s suicidality is a long process. Proper support in navigating this helps facilitate the grieving process.Maintaining a Relationship with the Deceased ParentFor children who lose a parent at a young age, they will miss their parent at many important moments in the future. Children may find comfort in maintaining a relationship with the deceased parent. Maintaining this relationship can help children in their grieving process.11, 13Explanation• Children can integrate positive qualities of the parent into their self-image, carrying a part of their parent with them.13• Keep talking about the deceased parent. Encourage the other parent to do this at home as well.• Involve the child in the grieving process and the funeral.• Even in the long term, the relationship can be maintained through memorial rituals, celebrating the deceased’s birthday, giving the child objects belonging to the deceased parent, preserving memories by writing stories or keeping journals, writing letters to the deceased parent, or visiting the deceased parent’s favorite places.11, 14
62Support in Grief ProcessingThere is some evidence that receiving social support after the loss of someone to suicide is associated with a reduced risk of depression and PTSD symptoms, as well as a decrease in grief symptoms.15 Some studies indicate that certain children may benefit from preventive interventions focused on grief processing.8, 16 However, robust evidence for effective interventions for suicide survivors is still lacking. If a child becomes stuck in their grieving process for an extended period, grief therapy (in the form of cognitive behavioral therapy) may help.17, 18Explanation• Unsolicited, routine referrals for grief processing can, in some cases, disrupt the natural grieving process.19• Everyone grieves in their own way and in their own time. Especially in cases of complex grief, such as after a suicide, this can be a long process.• Inform children where they can go if they need anonymous support, peer contact, grief counseling, or grief therapy.Grief from 0 to 4 years: Children at this age do not yet understand what death is or that it is permanent. Provide them with facts. Young children often express their feelings through behavior and play. For example, they may play with the deceased or reenact death.Grief from 5 to 8 years: Children begin to understand that death means someone will not return. At this age, they often ask many questions, which can be challenging. Try to answer honestly, as they often fill in what they don’t know with their own imagination.Grief from 9 to 12 years: Children have a good understanding of what death is. They are concerned with what others think and may not always express what they think or feel. Activities like playing, drawing, or crafting can help them express their feelings.Grief from 12 to 16 years: From this age, children understand death as well as adults do. They start to stand on their own and contemplate the meaning of life. The situation after a suicide can make this difficult. Let them know there is always room to talk and allow them the freedom to speak when they are ready.
63References1. Ratnarajah D. & Schofield M.J.(2007). Parental suicide and its aftermath: A review. Journal of Family Studies. 2007;13(1):78-93. doi:10.5172/jfs.327.13.1.782. Cerel, J., Fristad, M. A., Weller, E. B., & Weller, R. A. (1999). Suicide-bereaved children and adolescents: A controlled longitudinal examination. Journal of the American Academy of Child & Adolescent Psychiatry, 38(6), 672-679. https://doi.org/10.1097/00004583-199906000-000133. Cerel, J., Jordan, J. R., & Duberstein, P. R. (2008). The impact of suicide on the family. Crisis, 29(1), 38–44. https://doi.org/10.1027/0227-5910.29.1.384. Tal Young I, Iglewicz A, Glorioso D, et al. (2012). Suicide bereavement and complicated grief. Dialogues in Clinical Neuroscience. 14(2):177-186. doi:10.31887/DCNS.2012.14.2/iyoung5. Kuramoto, S.J., Brent, D.A. and Wilcox, H.C. (2009), The Impact of Parental Suicide on Child and Adolescent Offspring. Suicide and LifeThreatening Behavior, 39: 137-151. https://doi.org/10.1521/suli.2009.39.2.1376. Dyregrov A. (2008). Grief in Children: A Handbook for Adults (2nd Ed.). Jessica Kingsley Publishers.7. Cerel, J., Fristad, M. A., Weller, E. B., & Weller, R. A. (2000). Suicide-bereaved children and adolescents: II. Parental and family functioning. Journal of the American Academy of Child & Adolescent Psychiatry, 39(4), 437–444. https://doi.org/10.1097/00004583-200004000-000128. Pfeffer, C. R., Jiang, H., Kakuma, T., Hwang, J., & Metsch, M. (2002). Group intervention for children bereaved by the suicide of a relative. Journal of the American Academy of Child & Adolescent Psychiatry, 41(5), 505–513. https://doi.org/10.1097/00004583-200205000-000079. Mitchell, A. M., Wesner, S., Brownson, L., Gale, D. D., Garand, L., & Havill, A. (2006). Effective communication with bereaved child survivors of suicide. Journal of child and adolescent psychiatric nursing : official publication of the Association of Child and Adolescent Psychiatric Nurses, Inc, 19(3), 130–136. https://doi.org/10.1111/j.1744-6171.2006.00060.x10. Cain, A. C. (2002). Children of suicide: The telling and the knowing. Psychiatry, 65(2), 124–136. https://doi.org/10.1521/psyc.65.2.124.1993711. Hung, N. C., & Rabin, L. A. (2009). Comprehending childhood bereavement by parental suicide: a critical review of research on outcomes, grief processes, and interventions. Death studies, 33(9), 781–814. https://doi.org/10.1080/0748118090314235712. Silvén Hagström A. (2019). ”Why did he choose to die?”: A meaning-searching approach to parental suicide bereavement in youth. Death studies, 43(2), 113–121. https://doi.org/10.1080/07481187.2018.145760413. Normand, C.L., Silverman, P.R., Nickman, S.L.(1996). Bereaved children’s changing relationships with the deceased. In: Continuing Bonds: New Understandings of Grief. New York: Taylor & Francis.14. Adams, E., Hawgood, J., Bundock, A., & Kõlves, K. (2019). A phenomenological study of siblings bereaved by suicide: A shared experience. Death studies, 43(5), 324–332. https://doi.org/10.1080/07481187.2018.146905515. Scott, H. R., Pitman, A., Kozhuharova, P., & Lloyd-Evans, B. (2020). A systematic review of studies describing the influence of informal social support on psychological wellbeing in people bereaved by sudden or violent causes of death. BMC psychiatry, 20(1), 265. https://doi.org/10.1186/s12888-020-02639-416. Bergman, AS., Axberg, U. & Hanson, E. When a parent dies – a systematic review of the effects of support programs for parentally bereaved children and their caregivers. BMC Palliat Care16, 39 (2017). https://doi.org/10.1186/s12904-017-0223-y17. Andriessen, K., Krysinska, K., Hill, N. T. M., Reifels, L., Robinson, J., Reavley, N., & Pirkis, J. (2019). Effectiveness of interventions for people bereaved through suicide: a systematic review of controlled studies of grief, psychosocial and suicide-related outcomes. BMC psychiatry, 19(1), 49. https://doi.org/10.1186/s12888-019-2020-z18. Boelen, P. A., Lenferink, L. I. M., & Spuij, M. (2021). CBT for Prolonged Grief in Children and Adolescents: A Randomized Clinical Trial. The American journal of psychiatry, 178(4), 294–304. https://doi.org/10.1176/appi.ajp.2020.2005054819. Currier, J. M., Neimeyer, R. A., & Berman, J. S. (2008). The effectiveness of psychotherapeutic interventions for bereaved persons: a comprehensive quantitative review. Psychological bulletin, 134(5), 648–661. https://doi.org/10.1037/0033-2909.134.5.648
64Risk and protective factors for children’s health and development in families where a parent has a mental illness or has suicidal behavior.Resource 5: Factsheet risk and protective factors Social environmentChildRISK FACTORS• Substance abuse• Young when parent becomes ill• Poor self-esteem and self-worth • Feel guilty/takes the blame• Excessive responsibility at homePROTECTIVE FACTORS• Opportunities for mastery• Healthy diet • Good quality of sleep• Physical activity• Genetics• Information about mental health • Emotional and social support• Cose and good friendships • Good social skills• Effective coping strategiesPROTECTIVE FACTORS• Safe neighborhood• Supportive environment in school/daycare • High-quality schools/daycare • Positive relationships/close friends• Positive and mastery-filled leisure activities• Social inclusion and support• Family belonging • Good family communication and functioning• Access to quality services when help is needed• StabilityRISK FACTORS• Stigmatization• Social rejection and bullying• Social isolation
65Sources Hosman, van Doesum & van Santvoort (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. Australian e-Journal for the Advancement of Mental Health, 8(3). http//:10.5172/jamh.8.3.250 Hua, P., Huang, C., Bugeja, L., Wayland, S., & Maple, M. (2020). A systematic review on the protective factors that reduce suicidality following childhood exposure to external cause parental death, including suicide. Journal of Affective Disorders Reports, 2, 100032–100032. https://doi.org/10.1016/j.jadr.2020.100032Van Schoors, Van Lierde, Steeman, Verhofstad & Lemmens (2023). Protective factors enhancing resilience in children of parents with a mental illness: a systematic review. Frontiers in Psychology, 14. https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2023.1243784. http//:10.3389/fpsyg.2023.1243784 ParentsPROTECTIVE FACTORS• Good education and employment • Financial stability• Good mental and physical health• Spend quality time with children• Social support• Acceptance and validation of the child’s emotions• Good parenting behavior and caregiving competence: Positive, supportive, caring, accepting, warm, and present. RISK FACTORS• Substance use• Partner conflict• Neglect• Lack of parenting skills• Low monitoring• Violence and sexual abuse• Chronic or recurrent illness with severe symptoms and large functional impairment • Suicidal behaviorsThis factsheet can be used as a resource in the first meeting. It is useful for parents to know what factors can strengthen the child’s health and development. Focus on factors the family can influence. This overview is a simplified representation of a complex picture of factors influencing the child’s development. For each child these risk and protective factors influence the child in different ways depending on age, genes and other factors.
66Screening & Intervention Choices (SIC)1This is an additional tool for professionals to assess risk and protective factors in families and may be utilized in families in need of more detailed assessment of the family functioning and parenting skills. It will also help professionals to support the family and refer them to other services. The SIC form is not an assessment tool to evaluate the family. It is a resource for professionals to ensure provision of adequate support.How to use the SIC form?The Screening and Intervention Choices (SIC form) is a tool in screening families where one or both parents face mental health and/or substance abuse problems. By following the guidelines and asking a set of questions that cover a variety of topics, mental health workers will acquire the information needed to make a proper risk assessment of children from these families. The SIC form is not a test based on standardized score, but rather a theory-based tool used by the professionals to identify problems in families. Based on the individual assessment of the families concerned, those who need further support will be referred to interventions or other services. The SIC form can be used prior to, during, or after the conversation with the family. It may also be useful when professionals need further information on risk assessment after the meetings have taken place. There are three possible answers to each question, and the professional should circle the alternative that applies to the patient’s situation. – = Negative/poor/presence of responses+ = Positive/adequate/absence of responses? = UnknownIf a question does not apply to the patient, leave it blank. How to interpret the screening/answers?• Many negative scores indicate a risk factor for the child. • The SIC form will help you to select the interventions that suit the patient’s needs.• Positive scores suggest a protective/resiliency factor. • Many question marks suggest that the SIC form does not provide the necessary information in this case. • In order to gain a proper understanding of the risk and protective factors of the parents and their children, make sure to collect additional information on these areas in the following meetings.Resource 6: Screening & Intervention Choices (SIC) 1. Based on SIK-lijst van Boon, R., Dekkers, B. & Rikken, M. (1994), de ‘Screeningslijst’ developed by the Riaggs of the Hague and Screeningcard KOPP (Signalenkaart KOPP) developed by CGG Mandel en Leie Kortrijk en de regionale werkgroep KOPP-Zuid-West-Vlaanderen, Belgie. Revised (2010) by: Beijers, F. (RiaggZuid Roermond), Bellemakers, T. (Centrum Maliebaan Utrecht), Senders, A. (Prezens GGZ inGeest Amsterdam), Veldhoen, N. (Verslavingszorg Noord-Nederland Friesland).
67SIC FormDate of completion: .................................................................................................................................................................................................................................................................Filled in by:................................................................................................................................................................................................................................................................................................Name of the parent 1:...................................................................................................................................................................□ Man □ FemaleName of the parent 2:...................................................................................................................................................................□ Man □ FemaleInformation about the childrenName Date of birth SexLives at home:yes/no SchoolPsychiatric treatment? (specify)
68Part 1 ParentsIn case both parents have mental health problems, they should complete part 1 separately Screening– + ? Intervention choicea. Is the parent with mental illness aware of his/her mental health problems?If there are mainly negative scores: Improving the understanding of mental illness between the parents should be the main focus during the conversation (with the parent and/or partner).b. Is the 'healthy' parent aware of the mental health problems of his/her partner? – + ? Intervention choicea. Is the parent with mental illness aware of the impact of his/her mental health problems on the children?If there are many negative scores:• Give parent (s) advice on how to talk to their child about mental illness (the mental health worker and the parents can use the brochures or information cards for children)• Based on the needs of the parents, the mental health worker may facilitate the conversation between the parent/parents and their child/children.• Provide the parents with brochures that contain the relevant information. b. Is the other parent aware of the problems? c. Have the parents been informed about the services that can support their children? d. Is/are the parent/parents undergoing treatment or receiving support? If so, what kind of treatment and support?e. Have the parents talked with their children about their problems?1. Mental Health Awareness2. Impact of mental illness / suicide or suicide attempt on the childrenNote: - = Negative / poor / presence of responses, + = Positive / adequate / absence of responses, ? = Unknown
69– + ? Intervention choicea.How is the communication among members of the family?If there are many negative scores:If a and b: give information about negative consequences for the children or refer the parents to family counseling / therapy or family talk (if available) If c:• support the parents and offer quality care to the child in terms of (future) crisis• Referring the family to family care (specialized)If d:• Encourage the parents to talk with relatives and friends about their problems. • Encourage the parents to maintain a social network and / or to build one for themselves and their children (if necessary, through welfare / youth and community work)b. How is the relationship between the parents?c. Is the family stable?d.What kind of supports are available to the family outside the household?– + ? Intervention choicea. Emotional involvement If there are many negative scores for questionnaire 4, but a reasonable number of positive scores for questionnaire 5:• Give the parents the brochure (for parents) and /or refer them to the websites with information for parents who have mental illness of substance abuse disorder. Discuss the subject of «Good Enough Parenting» with the parents. • Inform the parents about other supportive services, such as the (online) course and in case of an infant refers to services like «the parent-baby intervention», which is aimed at parents with a baby until 12 months of age. b. Emotional availability and warmthc. Empathic abilities d. Patiencee. Capable of creating a family/household structuref. The ability to take the leading role in the family g. The ability to see the potential in the children in accordance with their age. h. Be the good role model as a parenti. Offer continuity of carej. Be predictable 3. Family communication4. The patient’s parenting competenceAssessment of patient’s parenting competence based on: Go to 5 if it concerns a bereaved parent, a partner of a parent who died by suicide
70– + ? Intervention choicea. Rate of wellbeing If there are many negative scores:• Provide information and refer the parents to other parenting support services. • Consider if the parenting tasks are taken over by others.• Discuss how social network and a supportive environment can be beneficial to the family.• Referring the family/parents to the following services based on their needs: • Community services such as the Youth Care Agency, home supervision (specialized), social work, etc.• Mental Health Care for children and youthb. Emotional availability and warmthc. Capable of establishing a family/household structure d. The capacity to take the leading role in the family e.The capacity to see the potential in the children in accordance with their age.f. Be the good role model as a parentg. Offer continuity of careh. Arrange social and outdoor activities for the children– = Negative / poor / presence of responses, + = Positive / adequate / absence of responses, ? = Unknown5. Other (bereaved) parent/ caregiver(An assessment of the other ( bereaved) parent’ supporting role)
71Part 2 ChildIn case the family have more than one child, the forms in part 2 should be completed for each child.a.Do the parents have any worries about the child? If so, what kind of worries? How long have the parents been worrying about the child?b.Are there any (serious) problems at home or in school? If so, what kind of problems and how long has the child been facing these problems? Name of the child: ____________________________________________ Age of the child: _______________– + ? Intervention choicea. Does the child have the appropriate information about the parent’s problems (adjusted to the child’s age)?If there are mainly negative scores:• Engage the child (up to 8 years of age) in the conversation. The child is encouraged to read the materials together with the parent (s). Discussions of the subject is recommended. – Use brochures that are suitable for children of different age.– Children may also be referred to available websites b. Does the child understand that the problems of their parents may have an impact on him or her?– = bad, + = good, ? = unclear7. The child’s perception of the parental mental illness6. The child’s wellbeing The general impression of the child’s wellbeing seen from the parents’ and/or the mental health worker’s point of view. .
72– + ? Intervention choicea. Brothers / Sisters If there are many negative scores:• Encourage the parents to give their consent so that the child can talk with health care professionals about the problems. • Ask the parents to encourage the child to develop social relations with friends / girlfriends, and other family members. • Give the child brochures and other relevant information ((if not already done).• Introduce the child available websites or apps. • Encourage the parents to think of other adults in their social circle, who can give support to their child.• Encourage foster parents/children to participate in sports and leisure activities. • Provide relevant information and encourage the child to become a member of support groups aimed at children/adolescents of different age-groups (6-8, 8-12, 13-15 and 16-23 years) if available.b. Familyc. Friends of the parent/parentsd. Neighbourse. Parents of the friendsf. Friendsg. Teachers / mentors at schoolh.Coaches and leaders of leisure activities (sports, scouting, music classes etc.)i. Mental Health Carej.Who are the most supportive people according to the child concerned? _________________________________– = bad, + = good, ? = unclear8. Child support is given by
73– + ? Intervention choiceIf there are many negative scores for questionnaire 9 and 10:- Ask the parent (s) to encourage their child to develop practical and important skills by following the advice below: - Discuss with the child the skills that can be useful for him/her. - Provide relevant information and encourage the child to participate in support groups/ peer groups If the child responds negatively to most questions, this can be seen as an alarming sign. Suggestions:- Consult with colleagues and / or refer the child to Mental Health Care for Children and Youth or Youth care agencya. The child has the ability to express feelingsb. The child has the ability to require attention, ask for information or helpc. The child has the ability to set limitsd. The child has the ability to distance him/herself from the parent’s mental illness or suicidal behaviore. The child has the ability to cope with stigma related to mental illness and negative reactions of the surroundings f. The child has the willingness and capability to participate in social activities – = bad, + = good, ? = unclear– + ? Intervention choicea. Feelings of guilt See aboveb. Feelings of shamec. Negative self-image (self-esteem)d. An (overly) strong sense of responsibilitye. Other important reactions: ____________________- = absent, += present, ? = unclear10. Direct responses from the child 9. Coping skills of the child
74– + ? Intervention choicea. Sleeping disorders If there are many negative scores:• Consult with colleagues and / or refer the child to:– Mental Health Care for Children and Youth– Youth Care Agencyb. Eating disorders c. Behaviour problemsd. Anxietye. Depressionf. High stressg. Concentration problems h. Physical problemsi. Poor school resultsj. Bedwettingk. Other non-specific reactions:_______________________________- = absent, += present, ? = unclearAdditional comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________11. Non-specific reactions from the child
75Illustration photo: VH-Studio / Mostphotos
76Resource 7: Evaluation of user satisfaction (to patients/clients/users)This is an example of how user satisfaction may be evaluated after delivery of the Child Talks intervention.You and your family have participated in Child Talks meetings. We kindly ask you to answer a few questions about your experience of the intervention meetings1) Please circle the correct answer.□ Both my child/children and I participated in the meetings. □ I participated in the meetings, but my child/children did not. 2) Please indicate the extent to which you agree or disagree with each of the following statements by using the scale provided. Scale 1 – Completely disagreeScale 2 – DisagreeScale 3 – Undecided/NeutralScale 4 – AgreeScale 5 – Completely agree1 2 3 4 5After participating the Child Talks, I have gained useful information about the consequences of my mental illness that may have for my child. After participating the Child Talks, I have deepened my understanding of my child’s situation.
773) The Child TalksPlease indicate the extent to which you agree or disagree with each of the following statements by using the scale provided. Scale 1 – Completely disagreeScale 2 – DisagreeScale 3 – Undecided/NeutralScale 4 – AgreeScale 5 – Completely agree1 2 3 4 5Child Talks was helpful for me as a parent.Child Talks was helpful for my children.Child Talks gave important information on what consequences parental mental disorder or suicidal behavior may have for the children.I understood the information I received during the talks.I felt that I was given the opportunity to ask all my questions during the talks. I understand my children much better as a result of the talks.Child Talks provided me with useful information, as well as advice on how to seek help and further support.Child Talks strengthened my belief that I am a good parentChild Talks helped to improve the wellbeing of my children.I would recommend Child Talks to other parents who are in the same situation.4) If you have more concerns and questions, please let us know. . Thanks very much for sharing your experience with us!
78In order to evaluate the effectiveness of the intervention program, we need to examine the key aspects of the project, including the number of participants, children’s baseline characteristics, post-intervention, and follow-up assessments.1 Each assessment should be carried out separately based on the following criteria:• Children’s wellbeing • Children’s resilience • Feelings of guilt and shame• Children’s problems and development status• Parents’ evaluation of children’s development status• Children’s knowledge of mental health literacy• Parenting competenceThe following measures are recommended:Sociodemographic variablesParental gender, age, marital state, living situation, education, work, income, as well as parental diagnosis and severity of parental mental disorder should be measured. Diagnosis can be retrieved from clinical records. Diagnoses should be based on structured clinical interviews as SCID 2 or MINI 3 and be codified with DMS IV, DSM 5 4 or ICD-10 5. Severity of parental mental disorder parent should be retrieved from clinical records or GAF score.4 Children’s baseline characteristics should include age, gender, living with mentally ill parent or not, total number of siblings, and educational attainment.The health-related quality of life (KIDSCREEN-27). 6The KIDSCREEN-27 is a measure for health- related quality of life for children from 8-18 years of age. It contains 27 items building five subscales: physical wellbeing, psychological wellbeing, autonomy and parents, social support and peers, and school environment. A 5-point Likert response scale is used in all subscales. All scores are reported as T-values, with higher scores indicating higher health- related quality of life. KIDSCREEN-27 was found to be a reliable and valid measure of quality of life in children and adolescents. The reliability of each of the five dimensions Cronbach Alpha is > 0.70. Answering the KIDSCREEN-27 requires 10-15 minutes.7 The Resilience Scale for Adolescence (READ). 8READ is a self-report questionnaire measuring resilience; the ability to handle stress and negative experiences. READ is a 28-item scale with positively formulated items organized in five subscales; personal competence, social competence, social support, family cohesion and structured style. Statements are answered on a 5-point Likert scale from 1 (completely disagree) to 5 (completely agree). Higher scores indicate higher degrees of protective characteristics associated with resilience within each domain. Subscale scores are summarized into a total score for resilience. Resource 8: Suggestions for evaluation (research and quality assurance)
79It takes five minutes to complete the questionnaire. READ shows adequate psychometric properties and promising validity when correlated with measures of mental difficulties.9Guilt and Shame Questionnaire for Adolescents of Parents with Mental Illness (GSQAPMI). 10This questionnaire includes 10 items, five items measuring shame and five measuring guilt. Adolescents are to answer how often they have experienced feelings of guilt and shame, with answers on a 5-point Likert scale ranging from 0 (never) to 5 (always). Reliability scores were found adequate in a previous study.10The Strengths and Difficulties Questionnaire (SDQ). 11SDQ is a brief behavioral screening questionnaire for children aged 3-16-year-old. The scale is composed of 25 items, divided between 5 scales; emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems, and prosocial behavior. Statements are answered on a 3-point Likert scale ranging from Not True, Somewhat True, to Certainly True. Reliability scores have been found adequate in previous studies.12Parents’ evaluations of child developmental status (PEDS). 13PEDS is a 10-question measure. The first item is an open-ended question where parents describe any concerns they may have about their children in terms of behavior, learning, and development. In the following 8 questions the parents consider whether they have concerns in each developmental domain and the final question probes any additional concerns. PEDS determines whether children are at (a) high risk for developmental problems, (b) moderate risk for developmental and/or mental health problems (c) limited risk but in need of in-office advice; or (d) limited/no risk.14 Reliability scores have been found adequate in previous studies. The questionnaire can also be used with caregivers other than parents.Parent-Child Communication Scale (PCCS). 15The Parent-Child Communication Scale consists of one scale for children and one for parents. The child report consists of 10 items, measuring children’s perceptions of their primary caregiver’s openness to communication. Statements are answered on a 5-point Likert scale from 1 (”almost never”) to 5 (”almost always”). The parent report reflects the child’s perception of the primary caregiver’s effort to maintain open communication with him/her. The child communication scale reflects the frequency with which the child communicates his/her feelings and problems with the primary caregiver. See: http://fasttrackproject.org/techrept/p/pcp/
80Children’s Mental Health Literacy Scale. 16The scale examines children’s knowledge of mental disorder, recovery, and stigma. The scale consists of multiple-choice questions developed for children of a parent with a mental disorder. The scale is currently being tested and will be ready for dissemination during the next year.Parenting Sense of Competence (PSOC). 17The PSOC is a 16-item measure intended to assess parents’ beliefs that they are capable of doing a good job parenting their child. It is comprised of two subscales and is rated on a 6-point scale from 1 (“strongly agree”) to 6 (“strongly disagree”). The efficacy subscale measures parents perceived competency (e.g. “Being a parent is manageable, and my problems are easily solved”), while the satisfaction subscale measures parental satisfaction (e.g. “Being a parent makes me tense and anxious”). Research on the PSOC has demonstrated adequate reliability and validity when used with parents of young children.17 The questionnaire can also be used with caregivers other than parents. User satisfaction. The satisfaction of health care users should be evaluated by a scale tapping into issues related to challenges of being a parent/caregiver with mental health problems.
81References1. Reedtz, C., Van Doesum, K., Signorini, G., Lauritzen, C., Amelsvoort, T. Van, Santvoort, F. Van, … Girolamo, G. De. (2019). Promotion of Wellbeing for Children of Parents With Mental Illness : A Model Protocol for Research and Intervention. Frontiers in Psychiatry, 10(September), 1–10. https://doi.org/10.3389/fpsyt.2019.006062. First, M.B.,Skodol, A.E., Bender, D.S. & Oldham, J.M. (2017). User’s Guide for the Structured Clinical Interview for the DSM-5-r Alternative Model for Personality Disorders. Arlington, USA: American Psychiatric Association.3. Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., Hergueta, T., Baker, R., & Dunbar, G. C. (1998). The MiniInternational Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. The Journal of Clinical Psychiatry, 59 Suppl 20, 22–57.4. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.97808904257875. World Health Organization (WHO). 2010. The ICD-10 Classification of Mental and Behavioural Disorders. Genève, Switzerland: World Health Organization.6. The Kidscreen Group Europe. The KIDSCREEN Questionnaires. In: Quality of Life Questionnaires for Children and Adolescents. Pabst Science Publishers (2006).7. Ravens-Sieberer ,U., Auquier, P., Erhart. M., Gosch, A., Rajmil, L., Bruil. J., et al. (2007) The KIDSCREEN-27 quality of life measures for children and adolescents: psychometric results from a cross-cultural survey in 13 European countries. Quality of Life Research, 16 (4), 1347–56. doi: 10.1007/s11136-007-9240-28. Hjemdal O. (2007). Measuring protective factors: the development of two resilience scales in Norway. Child and Adolescent Psychiatric Clinics of North America, 16 (2), 303–21. doi: 0.1016/j.chc.2006.12.0039. Askeland, K. & Reedtz, C. (2015) Måleegenskaper ved den norske versjonen av resilience scale for adolescents (READ). PsykTestBarn, 1, 3.10. Bosch, A., Van de Ven, M. O. M., & van Doesum, K. T. M. (2019). Development and Validation of the Guilt and Shame Questionnaire for Adolescents of Parents with a Mental Illness (GSQ-APMI). Journal of Child and Family Studies, 29, 1147–1158. https://doi.org/10.1007/s10826-019-01671-711. Goodman, A. & Goodman, R. (2009). Strengths and difficulties questionnaire as a dimensional measure of child mental health. Journal of American Academy of Child Adolescent Psychiatry, 48(4):400–3. doi: 10.1097/CHI.0b013e318198506812. Stone, L.L., Otten. R., Engels. R.C., Vermulst, A.A., Janssens. J.M. (2010). Psychometric properties of the parent and teacher versions of the strengths and difficulties questionnaire for 4- to 12-year-olds: a review. Clinical Child and Family Psychology Review, 13 (3), 254–74. doi: 10.1007/s10567-010-0071-2 13. Glascoe, F.P. (2003). Parents’ evaluation of developmental status: how well do parents’ concerns identify children with behavioral and emotional problems? Clinical Pediatrics, 42, 133–8. doi: 10.1177/00099228030420020614. Glascoe, F.P. (2014). Evidence-based early detection of developmental-behavioral problems in primary care: what to expect and how to do it. Journal of Pediatric Health Care, 29(1). doi: 10.1016/j.pedhc.2014.06.00515. McMahon R, Kim H, Jones K. Parent-Child Communication, Parent Report (Fast Track Project Technical Report). Seattle, WA: University of Washington (1997).16. Riebschleger, J., Costello, S., Cavanaugh, D. L., & Grové, C. (2019). Mental Health Literacy of Youth That Have a Family Member with a Mental Illness: Outcomes From a New Program and Scale. Frontiers in Psychiatry, 10 (February). https://doi.org/10.3389/fpsyt.2019.0000217. Johnston, C. & Mash, E.J. (1989) A measure of parenting satisfaction and efficacy. Journal of Clinical of Child Psychology, 18, 167–75.
82There are numerous resources available online internationally for children of parents with mental illness, substance use disorders, and families affected by parental suicide attempts and suicide (MISS). These resources aim to provide support, information, and guidance to help children and families navigate the challenges associated with parental mental illness. Each country may have its own specific resources, tailored to meet the unique needs of its population.To locate these resources, you can use various search words and topics, such as:• Children of parents with mental illness (COPMI) resources• COPMI support groups• Parental mental illness support• Mental health resources for families• Support for children with mentally ill parents• International COPMI resources• Mental health organizations for families• Online support for COPMI• Coping strategies for children of mentally ill parents• Educational materials for COPMI• Support for families affected by parental suicide or suicide attempts.By exploring these search terms, you can find information and support networks that can help families affected by MISS. Whether you are looking for educational materials, support groups, or professional guidance, there are many resources available to assist you.Resource 9: Other useful resources
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