Family-focused practice with EASE: A practice framework for strengthening recovery when mental health consumers are parents

Lived experiences of mental health nurses who care for clients who are parents: An approximation of Tronto's definition of care

WHAT IS KNOWN ON THE SUBJECT

Adult psychiatric services typically focus on the mental health needs of the client but they do not support his or her parenting role. Many authors highlight the importance of a non-judgmental approach when providing support and care to clients with mental illness who are parents. Assessments frequently focus on the negative aspects while the strengths of these families were often overlooked. There is a lack of scientific literature exploring nurses' experiences when caring for parents with mental illness and their families.

WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE

Trust is the basis that helps clients to be open to receiving care and answering parenting-related questions. Therefore, without adequate professional-client trust, some care and interventions addressed to parents with mental illness could be poorly received by the client. Tronto's phases of care facilitated the collection of data and exploration of mental health nurses' experiences of care.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

Mental health nurses should be aware of the potential needs of these families, as described in the scientific literature, so they can include them in their assessments. They also should consider the need to individualize each care since each situation of a family with parental mental illness is unique. Mental health nurses must take the person's environment into account (family, social and political aspects and different forms of stigma) since all these factors may influence how parents with mental illness receive and provide care.

ABSTRACT

Introduction Many authors highlight the importance of a non-judgmental approach when providing care to parents with mental illness. However, assessments frequently focus on the negative aspects while the strengths of such families were often overlooked. Aim To explore the lived experiences of mental health nurses who care for clients who are parents. Method We conducted a qualitative phenomenological study. The main data collection technique was in-depth interviews. Data were analysed according to Colaizzi model, subsequently, the main categories that arised were compared and related to the five phases of Tronto's care. Results The main categories identified from the analysis of the interviews were: (1) individualized care, (2) continuity of care, (3) psychoeducation and counselling, (4) trust and (5) context of the client. Discussion Trust is the basis that helps parents with mental illness to be open to receiving care and answering parenting-related questions. Without trust, some interventions could be poorly received by the client. Implications for Practice Mental health nurses should be aware of the potential needs of these families, so they can include them in their assessments. They also should consider the need to individualize each care since each situation of a family with parental mental illness is unique.

A qualitative study of health visitors' family focused practice with mothers with mental illness in Northern Ireland: Perspectives of health visitors, mothers and partners

BACKGROUND

Despite benefits of family focused practice, little is known about health visitor's practice with families when mothers are mentally unwell. Health visitors are midwives and nurses with additional training in community public health.

OBJECTIVES

To explore multiple perspectives of health visitor's family focused practice with families when mothers have mental illness in Northern Ireland.

METHODS

Ten health visitors, 11 mothers with mental illness and seven partners completed in-depth interviews in Five Health and Social Care Trusts. Participants were asked to describe their experiences of providing or receiving family focused practice within health visiting and data was analysed using thematic analysis.

RESULTS

Health visitors primarily addressed mothers and children's needs rather than also supporting partners. Additionally, they only addressed mother's needs associated with less severe mental illness (i.e. postnatal depression). Health visitors and mothers converged on many issues, including the influence of the health visitor's personal and professional experiences on their practice, central role of the relationship between health visitors and mothers and importance of health visitors supporting partner's well-being. While partners did not perceive that health visitors should support their well-being they expressed a need for further information and knowledge in order to support mothers.

CONCLUSION

Health visitor's practice largely centres around mother and baby. For health visitors to increase their family focused practice they need to meet needs of mothers who have serious mental illness more effectively and consider how partners can be included in their practice, in a manner that is beneficial and acceptable to them. This study contributes to better understanding of health visitor's family focused practice with mentally ill mothers and highlights the need for more effective engagement with mothers with serious mental illness and partners. It also highlights that for health visitors to engage in family focused practice they need the necessary training and time to do so. Results can inform organisational developments in family focused practice within health visiting.

Parenting and family life experiences of mothers diagnosed with schizophrenia within Chinese cultural context

WHAT IS KNOWN ON THE SUBJECT?: Parenting experiences are a great challenge but also a meaningful achievement for mothers diagnosed with schizophrenia (MDWSs). Most previous studies focused on the parenting experiences of Chinese mothers diagnosed with depression rather than those diagnosed with schizophrenia, who usually experience psychiatric symptoms. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Unlike in Western society, Chinese society is characterised by a family-centred culture. This study insightfully explores MDWSs' parenting and family life experiences addressing their intrapersonal mindsets, interpersonal connections with family members across generations and extrapersonal roles such as traditional social expectations as a mother, wife and daughter-in-law. While Western studies have mainly focused on MDWSs' personal resilience, this study insightfully explored MDWSs' resilient dimensions including their personal, familial and cultural issues within the Chinese society. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This study develops a comprehensive and professional understanding of the parenting experiences and family interactions of MDWSs who struggle to achieve their motherly role and re-establish connections with intimate family members. The findings highlight the following important considerations when offering family-based nursing cares: (1) assess power relationships, familial dynamics and cultural influences between MDWSs and their family members; (2) extend family members' involvement, such as parents-in-law, while offering psychoeducation to MDWSs and their family members. ABSTRACT: Introduction In Chinese culture, raising the next generation is recognised as a crucial family matter involving intergenerational participation. Mothers diagnosed with schizophrenia (MDWSs) usually experience high stress due to psychiatric symptoms, different parenting values across generations and traditional expectations associated with motherly roles. MDWSs need urgent professional assistance. Aim To explore MDWSs' parenting experiences and family life in Chinese cultural contexts. Method In-depth interviews were conducted with 20 MDWSs. Data were analysed using interpretative phenomenological analyses. Results The superordinate theme was identified as 'You are not a qualified mother'. Three major themes were elicited: experiencing crises in parenting, family life and self-stability; striving to be a good mother and wife under humiliation; and developing wisdom and courage to move forward. Discussion A dehumanised attitude of family members in a paternalistic culture was found. While Western society focuses on personal resilience and family-based nursing care for nuclear families, Chinese society intensively focuses on MDWSs' relationship with nuclear family members as well as extended family members such as parents-in-law. Implications for Practice The results highlighted the significance of culturally sensitive nursing care for MDWSs and family-centred psychoeducation that clarifies familial dynamics and improves effective communication between MDWSs and their family members.

Predictors of family-focused practices among mental health workers in Quebec

Context

Engaging family members in the ongoing care of individuals with mental illness is a practice known to bolster the client's recovery journey and enhance the overall wellbeing of both children and families involved. Despite its potential benefits, there remains a dearth of understanding surrounding the implementation of family-focused practices (FFP) by mental health professionals serving adults, as well as the factors that could either promote or hinder such practices. This knowledge gap is particularly pronounced within North American settings.

Goal

The goal of this study was to identify potential hindering and enabling factors of FFP used in adult mental health services.

Methods

A sample of 512 professionals working with adult mental health clients, from all regions of Quebec, Canada, with a variety of disciplinary backgrounds and working in different work settings, completed the Family Focused Mental Health Practice Questionnaire (FFMHPQ). Multinominal logistic regression analysis was performed to assess the impact of several factors - organizational, professional, and personal - on the degree of family-based practices of mental health workers.

Results and discussion

Findings of this study show that the strongest predictors for the adoption of higher FFP levels among adult mental health professionals in Quebec, are being employed on a full-time basis, perceiving a higher level of skills, knowledge, and confidence toward FFP, and having a supportive workplace environment. Results underscore the need to address both organizational and worker-related aspects to effectively promote better FFP in mental health services.

A Vicious Circle of Hope and Despair: Stigma Experienced by Relatives of Persons with Severe Mental Illness

Not only people suffering from severe mental illness (SMI) but also their family members experience stigma. Relatives are met with negative attitudes from healthcare professionals, which adds to the problem. This Swedish study employed a qualitative inductive explorative design in the analysis of written free-text responses from 65 persons who completed a questionnaire for relatives of persons with SMI. The overarching theme, "A vicious circle of hope and despair", was elaborated by four categories which formed a vicious circle: "Wanting openness, understanding and acknowledgement"; "Facing a lack of understanding from others"; "Seeking understanding from mental healthcare professionals but experiencing the opposite"; and "Keeping family experiences private." If this vicious circle of family stigma is to be broken, measures are needed for both relatives and health care professionals.

Health and social care professionals' views and experiences of supporting parents with serious mental illness

Introduction

A significant number of individuals with a serious mental illness (SMI) such as schizophrenia or bipolar disorder are also parents of dependent children. Despite the risk of adverse psychological, behavioral, and social outcomes their needs often go unmet. To better understand the needs of parents with SMI and their children it is necessary to gain insight into the perspectives and experiences of the professionals in adult mental health and children's services who work with them, and who, ultimately, are best placed to meet those needs.

Aims

To explore the views and experiences of health and social care professionals working with parents with SMI to understand the needs of, and their role supporting, parents with SMI and their children.

Methods

Semi-structured interviews were conducted with seventeen professionals from six NHS and Local Authority settings in England, UK. Participants were included if they were employed in adult mental health or local authority children's services and had experience of working with parents with SMI. Sampling was purposive, including a wide range of professions in these settings. Interview data were analyzed using template analysis taking a critical realist perspective.

Results

Three top-level themes were generated: (1) Impact of parental SMI on the child, (2) Accessing support from services, (3) Role of professionals working with parents with SMI. Themes highlight diverse, wide-ranging effects of SMI on the child and a reluctance from parents to seek help due to stigma and fear. Available services are reported to be inaccessible and unacceptable to parents with SMI and practitioners experience conflict when balancing the needs of the parent and child. A whole-family approach facilitated by improved communication between services is advocated.

Conclusion

Participants believed that parents with SMI experience complex parenting challenges over and above other parents, describing a largely detrimental impact on the child. Support services were deemed inadequate, and participants stressed the need to develop specialist services tailored toward the needs of parents with SMI and their children. Although participants endorsed joined up working across health and social care settings to facilitate a whole family approach, they required greater service knowledge and training in parental SMI.

Parenting and Serious Mental Illness (SMI): A Systematic Review and Metasynthesis

The consequences of Serious Mental Illness (SMI) on parent and child outcomes can be profound. Supporting parents to manage their caregiving roles alongside parental SMI successfully has been recognised as a public health priority. To meet this priority and develop effective and acceptable interventions, it is imperative that parents' experiences and support needs are understood. This systematic review aimed to synthesise qualitative research that explored parents' experiences and perceptions of the impact of SMI on their parenting and their corresponding support needs. The Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines were followed. Five databases were searched for terms associated with SMI, parenting, and qualitative research. Twenty-nine studies involving 562 parents who experienced SMI met inclusion criteria, and the methodological quality of included studies was appraised using the Critical Appraisal Skills Programme. After findings were synthesised using thematic synthesis, six themes were identified: (1) The constrained parent, (2) parenting difficulties, (3) the strained child, (4) inescapable threat, (5) combatting threat, and (6) wrap-around support needs. Novel insights into the centrality of SMI-related parenting difficulties and threat perceptions across parent, family, healthcare, and wider social systems on strained parent-child and distanced parent-support relationships were highlighted. Systemic practice change initiatives via compassionate and inclusive system-wide support were recommended.

Validation of the family focused mental health practice questionnaire in measuring health and social care professionals' family focused practice

BACKGROUND

Parental mental illness is a major public health issue and there is growing evidence that family focused practice can improve outcomes for parents and their families. However, few reliable and valid instruments measure mental health and social care professionals' family focused practice.

OBJECTIVES

To explore the psychometric properties of the Family Focused Mental Health Practice Questionnaire in a population of health and social care professionals.

METHODS

Health and Social Care Professionals (n = 836) in Northern Ireland completed an adapted version of the Family Focused Mental Health Practice Questionnaire. Exploratory factor analysis was used to test the structure of the underlying dimensions in the questionnaire. The results, and theoretical considerations, guided construction of a model that could explain variation in respondents' items. This model was then validated using confirmatory factor analysis.

RESULTS

Exploratory factor analysis revealed that solutions including 12 to 16 factors provided a good fit to the data and indicated underlying factors that could be meaningfully interpreted in line with existing literature. From these exploratory analyses, we derived a model that included 14 factors and tested this model with Confirmatory Factor Analysis. The results suggested 12 factors that summarized 46 items that were most optimal in reflecting family focused behaviours and professional and organizational factors. The 12 dimensions identified were meaningful and consistent with substantive theories: furthermore, their inter-correlations were consistent with known professional and organizational processes known to promote or hinder family focused practice.

CONCLUSION

This psychometric evaluation reveals that the scale provides a meaningful measure of professionals' family focused practice within adult mental health and children's services, and the factors that hinder and enable practice in this area. The findings, therefore, support the use of this measure to benchmark and further develop family focused practice in both adult mental health and children's services.

Carer involvement in the assessment of personal recovery: A naturalistic study of assertive community treatment in Norway

Background

The user and carer movements have come a long way in becoming embedded in mainstream mental health services for individuals with serious mental illness. However, implementing recovery-oriented practice continues to be plagued by an individualistic clinical focus. The carers do not feel integrated despite policies and best intentions. The implementation of Assertive Community Treatment (ACT) provided an opportunity to involve the carers and compare their assessment of personal recovery with the users.

Aims

The aims of this study were to examine (i) how family carers and users differed in their assessment of personal recovery, (ii) whether familial and personal relationships influenced how carers assess personal recovery of users, and (iii) if the experience of family carers with the ACT team was associated with personal recovery.

Methods

The naturalistic, explorative study recruited 69 users and 36 family carers from 12 Norwegian ACT teams. The users and carers assessed the user's personal recovery. Family carers also reported their experience and satisfaction with the ACT teams. Analyses included independent and paired sample T-tests and correlation analysis.

Results

Family carers were significantly more conservative than the users' assessment of the intrapsychic and interpersonal subscales of personal recovery. The pattern held true whether the family carers were matched to the users or part of the total sample. Lastly, there was a significant negative correlation between the family carer's experience of cooperation with the ACT team and their assessment of the user's intrapersonal process of recovery.

Conclusions

The results of our study were consistent with previous research on carer involvement in MHS. However, it is the first study that engaged carers and assessed personal recovery of the users of ACT services. Discrepancy between carers and users is the rule. Clinicians are encouraged to embrace the discrepancy and diversity carers bring and learn the methodology of multi-informant assessments. There also is a need to address, update, and integrate the personal, familial, and relational aspects of recovery. Modification of recovery measures such as QPR and their creative use with carers has the potential to generate valuable third-party information and to involve them meaningfully in mental health services.

Living with parental mental illness is like a roller coaster: Reflections on children's lifeworld in the family setting

AIMS AND OBJECTIVES

To explore what it is like for children in the family setting to live with parental mental illness.

BACKGROUND

There are reported risks of negative social and behavioural outcomes among children living with parental mental illness such as poor school performance, isolation and poor mental health. There is yet more to know about how children's interactions with significant members of the family shape their experiences.

DESIGN

A phenomenological design following Husserl's concepts of lifeworld and inter-subjectivity was adapted for the study.

METHOD

Twenty-one children (ages 10-17) who lived with a parent with mental illness were interviewed. The data were analysed to attain the essential features of the phenomenon. The study followed the COREQ checklist for qualitative studies.

FINDINGS

The essence of the phenomenon 'living with parental mental illness' in the family setting comprises strain, sadness and some happy moments. Living with parental mental illness can produce unpredictable life situations for children as relationships and interactions in the family setting can be chaotic and confusing. The ups and downs define their lifeworld as a roller coaster. Strenuous family environment, sibling interaction, navigating separate living arrangements and there are good days were specific themes that clarified the children's lives as a roller coaster.

CONCLUSION

A concept called the 'parent paradox' is coined to reflect how children are torn between what their living situation looks like comparing the parent with mental illness and the other without mental illness. The paradox is founded on children's loyalty towards their parents.

RELEVANCE TO CLINICAL PRACTICE

To break the unhealthy cycle created by the parent paradox, mental health nurses should ensure that children are well informed about the parent's mental condition including information about treatment procedures and recovery. Child's psychological distress may be reduced when they are informed.

Promoting Self-Determination in Parents With Mental Illness in Adult Mental Health Settings

This article reports a strengths-based intervention to support parents with mental illness and their children in adult mental health settings: "Let's Talk About Children" (LTC) intervention. A qualitative methodology was adopted with parent participants receiving LTC in adult mental health and family services. The benefits for parents receiving LTC were described through in-depth interviews with 25 parents following the delivery of the program. Interview data identified an impact on parental self-regulation-mainly through a change in a sense of agency as a parent-and skill building, once a clearer picture of their child's everyday life was understood. This study outlines the benefits of talking with parents about the strengths and vulnerabilities of their children during routine mental health treatment. The role for self-determination of parents in preventive interventions for children is an important consideration for mental health recovery, and it also helps to break the cycle of transgenerational mental illness within families.

Perspective: Implications of the COVID-19 Pandemic for Family-Focused Practice With Parents With Mental Illness and Their Families

The goal of this perspective piece is to suggest challenges to family-focused practice with parents with mental illness and their children that have emerged during the COVID-19 pandemic. We discuss implications for practice, policy, and research that will benefit from rigorous study in the future, as we sift through lessons learned. The impact of the pandemic on the mental health and well-being of people around the world has been documented. Common adaptations in service delivery have included a shift to telehealth and digital tools. The pandemic has posed challenges to practice across the EASE Framework components for family-focused practice (i.e., Engage, Assess, Support, and Educate) for both parents/families and practitioners. Governmental policy and funding responses will be critical to addressing the impact of stresses, disruptions and losses endured during the past months. Pandemic experiences and consequences have implications for research measures, methods, and outcomes, given the dramatic changes in people's lives and the contexts in which they live. The shift to research implementation in virtual environments has resulted in challenges in maintaining confidentiality, and the privacy and security of data. As we move forward, it will be important to acknowledge the remaining uncertainty about the future and accommodate the profound changes in family life, professional practice, and research implementation related to the pandemic in our efforts to demonstrate the effectiveness of positive lessons learned while developing new approaches for dealing with the negative consequences of the pandemic.

Editorial Perspective: Prato Research Collaborative for change in parent and child mental health - principles and recommendations for working with children and parents living with parental mental illness

Children whose parents have mental illnesses are among the most vulnerable in our communities. There is however, much that can be done to prevent or mitigate the impact of a parent's illness on children. Notwithstanding the availability of several evidence-based interventions, efforts to support these children have been limited by a lack of adequate support structures. Major service reorientation is required to better meet the needs of these children and their families. This editorial provides recommendations for practice, organisational, and systems change.

Nurses' views and practices on parental mental illness: An integrative review

When a parent has a mental health problem, family members can be affected by it. Nursing professionals can provide care for the whole family, including children. Nurses can support the parental role of parents with mental illness. This integrative review aimed at the following: To identify and to synthesize the views and practices of nurses on parental mental illness (PMI). An integrative review methodology was employed, following PRISMA guidelines. Theoretical and empirical literature was included. Twenty-three articles were obtained to be analysed, using the Whittemore and Knafl approach. A lack of knowledge about nurses' views and practices on PMI was found. Especially, in some demographic areas such as Mediterranean countries and Central and South America. Different issues which influence how nurses perceive PMI were identified: subjective meaning of family concept, personal experience of being parent, and perceptions of mental illness, among others. The main findings on nurses' practices were as follows: guidelines to implement family-focused practices, knowledge, and skills; therapeutic relationship; and teamwork and interagency communication; among others. These issues are intimately related. They could act as enablers or barriers to support parental role of parents with mental illness. Adequate guidelines and policies are necessary to support parents with mental illness and their families. There is a need to include knowledge about PMI and family-focused approach in nursing education curricula. Training could include reflection on nurses' experiences and personal values to become aware of how these can affect their interventions and practices.

Development of an Evidence-Informed and Codesigned Model of Support for Children of Parents With a Mental Illness- "It Takes a Village" Approach

Providing support to parents and their children to help address the cycle of intergenerational impacts of mental illness and reduce the negative consequences for children is a key focus of selective prevention approaches in public mental health. However, a key issue for children of parents with a mental illness is the lack of access to early intervention and prevention support when needed. They are not easily identifiable (until presenting with significant mental health issues of their own) and not easily accessing the necessary support that address the complex interplay of parental mental illness within families. There are significant barriers to the early identification of these children, particularly for mental health care. Furthermore, there is a lack of collaborative care that might enhance identification as well as offer services and support for these families. The "It takes a Village" project seeks to improve mental health outcomes for children through the co-development, implementation and evaluation of an approach to collaborative practice concerned with the identification of families where a parent has a mental illness, and establishing a service model to promote child-focused support networks in Austria. Here we describe the development of service delivery approach for the "It takes a Village" project that aims to improve identification and support of these children within enhancements of the existing service systems and informal supports. The paper describes the use of codesign and other implementation strategies, applied to a research setting, with the aim of impacting the sustainability of workforce reform to achieve lasting social impact. Results highlight the steps involved in translating evidence-based components, local practice wisdom and lived experience into the "It takes a Village" practice model for Tyrol, Austria. We highlight through this paper how regional context-specific solutions are essential in the redesign of care models that meet the complex needs of children of parents with a mental illness. Service system and policy formation with local and experienced stakeholders are also vital to ensure the solutions are implementation-ready, particularly when introducing new practice models that rely on organizational change and new ways of practice with vulnerable families. This also creates a solid foundation for the evaluation of the "It take a Village" approach for children of parents with a mental illness in Austria.

A Sustainability Model for Family-Focused Practice in Adult Mental Health Services

BACKGROUND

Translating evidence-based practice to routine care is known to take significant time and effort. While many evidenced-based family-focused practices have been developed and piloted in the last 30 years, there is little evidence of sustained practice in Adult Mental Health Services. Moreover, many barriers have been identified at both the practitioner and organizational level, however sustainability of practice change is little understood. What is clear, is that sustained use of a new practice is dependent on more than individual practitioners' practice.

DESIGN AND METHOD

Drawing on research on sustaining Let's Talk about Children in adult mental health services and in the field of implementation science, this article proposes a model for sustaining family focused practice in adult mental health services.

SUSTAINABILITY MODEL FOR FAMILY-FOCUSED PRACTICE

An operational model developed from key elements for sustaining Let's Talk about Children identifies six action points for Adult Mental Health Services and their contexts to support the sustainability of family-focused practices. The model aims to support Services to take action in the complexity of real-world sustainability, providing action points for engaging with service users and practitioners, aligning intra-organizational activities, and the wider context.

CONCLUSION

The model for sustaining family-focused practice draws attention to the importance of sustainability in this field. It provides a practical framework for program developers, implementers, adult mental health services and policy-makers to consider both the components that support the sustainability and their interconnection. The model could be built on to develop implementation guides and measures to support its application.

An exploration of whether mental health nurses practice in accordance with The Family Model

BACKGROUND

The Family Model is increasingly used as a framework to promote a whole family approaches in mental health services. The purpose of this qualitative study was to (i) explore whether nurses practice in accordance with the Model when providing services for parents who have mental illness, (ii) determine whether components of the model are employed more in some workplaces (i.e. acute in-patient units versus community settings) and (iii) ascertain reasons as to why this may be the case.

METHOD

A purposive sample of 14 nurses from eight mental health services in Ireland, completed semi-structured interviews.

RESULTS

Findings indicated that nurses' practice incorporated most key components of The Family Model, including supporting service users' dependent children. However, some practices were not explicit in the Model, such as supporting other adult family members (i.e. grandparents). While nurses' practice in community settings was more aligned with The Family Model than in acute in-patient units, there was a notable absence of reference to domain six (cultural considerations) in both settings. A holistic and family-centered philosophy, coupled with collegial and managerial support and a focus on prevention were the main features that enabled family focused practice in community settings.

CONCLUSION

As only a subgroup of nurses practice in accordance with The Family Model, efforts are required by nurses, their organisations and the broader system to promote family focused practice. The Family Model may be a useful framework, with further refinement, for guiding nurses' practice.

Adult Mental Health Outpatients Who Have Minor Children: Prevalence of Parents, Referrals of Their Children, and Patient Characteristics

Background: A strong connection exists between parental mental illness and lifetime mental health risk for their children. Thus, it is important to determine, when parents attend for treatment for their illness, the prevalence and characteristics of parents with a mental illness and identify referral actions for their children. Previous studies indicate that 12-45% of adult mental health service patients are parents with minor children. There is a need for studies with larger sample sizes that investigate the prevalence and characteristics of parents, and factors associated with referral actions for their children. Method: Data on 23,167 outpatients was drawn from a national census study across 107 Norwegian adult mental health outpatient clinics during 2 weeks in April 2013. Clinicians identified various socio-demographic characteristics of patients who were parents and referral actions for their children. Results: Eight thousand thirty-five (36%) of outpatients had children under 18 years. Thirty-one percent were provided with referrals for their children and 58% were reported to have children with no need for referral. Three percent were reported to have children with unmet needs who were not referred. There were missing data on children's needs and referral actions for 8% of parents. Patients who care for minor children were more likely to be refugees, and less likely to be single, male, not own a house/apartment, and have a schizophrenia spectrum illness or substance use disorder. Children were more likely to be referred when their parent was single, with no income from paid work, low education, not owning house/apartment, poor family network, long outpatient treatment, and an individual care plan; and less likely for men with a moderate or less severe mental illness. Children were referred to child protection agencies, child and adolescent mental health services and school psychological/pedagogic services. Discussion: The prevalence of outpatients with children is similar to other studies. Referrals were made for children of one third of outpatients with minor children. Needs and referrals of children was unknown for one in ten outpatients. Mental health outpatient clinics must improve procedures to identify parenting status and ascertain and act on children's needs.