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A randomised controlled trial of the Solihull Approach ten-week group for parents: ‘Understanding your child’s behaviour’ (UYCB).

06 September 2019

Hazel Douglas and Rebecca Johnson assess the impact of a parenting programme based on the Solihull Approach on child behaviour, parental emotional health and child-parent relationships, which addresses previous studies’ methodological weaknesses.

 

Research summary

  • Researchers evaluated the manualised Solihull Approach group ‘Understanding your child’s behaviour’ (UYCB), a 10-week course available universally to a population of parents/carers of children aged 0 to 19 years.
  • This was a parallel-group, non-matched samples, randomised controlled trial where participants were allocated to an intervention or wait-list control group. The absence of a control group and small sample size had been weaknesses in methodology in previous studies (Baladi et al, 2018).
  • Data was collected from 249 participants from Wrexham in Wales and Solihull in England between April 2013 and September 2017, with 223 in the experimental group and 26 in the control group.
  • All eligible prospective attendees (those who booked a place on a course) of UYCB were invited to participate in the study.
  • The majority were female (92.4%), with an ethnic mix consistent with the Office for National Statistics estimates for the UK population.
  • Three self-report measures were used at two time-points – pre- and post-intervention – measuring child behaviour, parental emotional health and child-parent relationship.
  • Participants’ responses in the intervention group were compared with waiting-list controls, after controlling for pre-test scores, by analysis of covariance, as per protocol.

Introduction

Parenting programmes are group-based interventions aimed at helping parents develop skills for working positively with their children to reduce or prevent the development of behavioural difficulties (Lindsay, 2019). They have been shown by many studies to benefit individuals (e.g. Furlong et al, 2013; Barlow and Coren, 2017), with positive impact on parental psychosocial health (Barlow et al, 2014); parents’ sense of competence (Lindsay and Totsika, 2017) and satisfaction (Lofgren et al, 2017), and to benefit society. For example, studies show parenting courses can not only return the financial investment, but provide a saving in costs to society. Estimates vary widely, but all models indicate a substantial saving over the cost of delivering a group for parents. Scott et al (2001) estimated that parenting courses can save 10 times their cost. Bonin et al (2011) estimated that £16,000 would be saved whilst Parsonage et al (2014) estimated a saving to society of £260,000 over 20 years for a child at risk of developing conduct disorder (Parsonage et al., 2014). 

The Solihull Approach model was developed in the late 1990s collaboratively between Solihull Health Visitors and the local NHS Child Psychology service. Supporting practitioners to move away from behavioural advice-giving towards a holistic assessment, with a relationship focus, was found to be transformative (Douglas, 2018). The emerging model, which integrates psychoanalytic theory (containment) with child development research (reciprocity) and learning theory (behaviour management) (Douglas, 1999). The aim was to increase the emotional health and well-being of children and parents, by emphasising the links between behaviour and emotions, focusing on parental as well as child emotional regulation, and enhancing practitioner-parent and parent-child relationships. 

More attuned parenting, with better child-parent relationships, should contribute to a reduction in what are now widely known as Adverse Childhood Experiences (ACEs), a term originally coined by Felitti et al in 1998, as well as increase the ability to process the experience of trauma and adversity, thereby decreasing the wide ranging impact of ACEs across the lifespan (Crouch et al, 2019). 

In 2006 the Solihull Approach model was introduced directly to parents, rather than through workforce development alone.  This was done by being structured as a 2 hour x10 week group for parents, with set topics and activities each week as described in a Facilitators’ Manual. 

‘Understanding your child’s behaviour’ (UYCB) was designed to encourage a move away from a ‘command and control’ way of parenting, with the primary objective of enabling good quality parent-child relationships. This is not to throw out behaviour management but this is customised within a wider understanding of behaviour as communication and the ways in which relationships help children learn to regulate themselves.

Previous quantitative and qualitative research into UYCB has shown positive outcomes for parents, child behaviour (Bateson et al., 2008; Cabral, 2013) and the child-parent relationship (Baladi et al., 2018), which were maintained at follow-up (Baladi et al., 2018). It also has high satisfaction ratings for helping parents understand their child and make changes to their parenting (Johnson and Wilson, 2012; Appleton et al., 2016; Vella et al., 2015).

This paper describes a randomised controlled trial (RCT, registration number ISRCTN15450239) of UYCB, with time as the allocation method. There are ethical difficulties with RCTs for parenting groups that rely on allocating a help seeking parent to a no treatment method, even if later they go on to receive help. Imposing a longer than otherwise ‘artificial’ wait by allocating to a no treatment group adds additional risk to the developing child, in that issues for which the parent is seeking help may escalate and become more entrenched. In the UK UYCB tends to run during three school terms per academic year, and are closed groups i.e. new parents may not join after week two. Therefore, in normal practice a parent enquiring after this point must wait to join a group the following term. This creates a ‘natural’ wait, with randomisation created by the point in time a parent requests help, if the trial is run for a minimum of twelve months.

Study aim 

The objective of the present study is to examine whether attendance at UYCB results in positive changes in parents’ perceptions of: their own emotional health; the child’s behaviour, and/or their relationship with their child(ren). 

The primary hypothesis was that UYCB would result in improved closeness subscale scores on the CPRS and decreased conflict subscale scores and, consistent with previous studies (Alexandris et al. 2013; Cabral, 2013), an increase in prosocial behaviours and reduction in conduct problems displayed by the child, as measured by the ‘prosocial’ and ‘conduct problems’ subscales of the SDQ.  

The secondary hypothesis was that attendance at UYCB would also result in improvements in parental wellbeing (DASS-21 scores) and overall child behaviour (SDQ scores). 

Ethics

The study was approved by the NHS Research Ethics Service West Midlands - Coventry and Warwick (Ref: 14/WM/0115).

Design

This was a parallel-group, non-matched samples, randomised controlled trial (RCT) where participants were allocated to an intervention or wait-list control group. The randomising factor was time of enquiry about the availability of a parenting programme. 

Participants

Data were collected from 249 participants from two areas of the UK: Wrexham, Wales and Solihull, England, between April 2013 and September 2017, 223 in the experimental group and 26 in the control group. The asymmetric sample sizes were sufficient for detecting any potential effects of the intervention, as described later. Participants’ children ranged from 1 to 19 years, with the majority of children under 11 years in both groups (79%). Both areas run UYCB as part of Local Authority parenting support strategies and both include suburban and rural areas with mixed demographic profiles. 

All eligible prospective attendees (those who booked a place on a course) of UYCB were invited to participate in the study. See Table 1 for inclusion and exclusion criteria. Participants did not need to be experiencing difficulties with the child for whom they cared. The majority were female (92.4%), with an ethnic mix consistent with the Office for National Statistics estimates for the UK wide population. See Table 2 for demographic characteristics in each group.  

 

Inclusion Criteria

Exclusion Criteria

Caring responsibility for child(ren) aged 0-18 years

Attendance of fewer than 7 out of 10 group sessions, with sessions missed occurring on consecutive weeks

Parents/carers who have expressed an interest in improving their understanding of their child’s behaviour by attending a Solihull Approach parenting group

 

Table 1. Participant Inclusion and Exclusion Criteria.


 

 

 

Intervention Group

 (n= 223)

Control Group

(n= 26)

Age (years)

Under 20

3

1.3%

0

0.0%

20-29

67

30.0%

11

42.3%

30-39

92

41.3%

9

34.6%

40-49

46

20.6%

3

11.5%

50+

14

6.3%

0

0.0%

Unknown

1

0.4%

3

11.5%

Gender

Female

205

91.90%

25

96.2%

Male

18

8.10%

1

3.8%

Parental/

caring status

Parent/step-parent

214

96.0%

24

92.3%

Grandparents/other relative

4

1.8%

0

0.0%

Adoptive parents /foster carer

2

0.9%

1

3.8%

Professional carer

1

0.4%

0

0.0%

Unknown

2

0.9%

1

3.8%

Single parents

 

54

24%

7

27%

Ethnic origin

White European

187

83.9%

20

76.9%

Asian/Asian British (includes Indian, Pakistani, Bangladeshi, 'Asian other')

17

7.6%

1

3.8%

Mixed/multiple ethnicity

8

3.6%

0

0.0%

Black/African/ Caribbean/Black British

5

2.2%

0

0.0%

Other

4

1.8%

0

0.0%

Unknown

2

0.9%

5

19.2%

Children

Average number of children per participant

2.22

 

2.69

 

Age range of children

0-19 years

 

0-19 years

 

Under 11 years

401

79%

55

79%

Boys

284

56%

40

57%

Girls

226

44%

30

43%

Employment status

Employed full time

15

6.7%

4

15.4%

Employed part time

44

19.7%

5

19.2%

Self employed

6

2.7%

0

0.0%

Full time parent/carer

136

61.0%

15

57.7%

In training/education

8

3.6%

1

3.8%

Unable to work

8

3.6%

1

3.8%

Retired

1

0.4%

0

0.0%

Unknown

5

2.2%

0

0%

Table 2. Showing baseline demographic characteristics for each group


Procedure

UYCB groups were held concurrently at multiple venues in the two areas during three academic terms, between 2013 and 2017. Groups were advertised through universally accessible services for families (e.g. children’s centres, schools, nurseries) and the usual professional networks for the parenting support teams in both areas (e.g. community practitioners, education support staff, early help services). Participants voluntarily contacted Flying Start (Wrexham) or the Parenting Team (Solihull) with a request to join a Solihull Approach group or were referred by local community services. If contact was made before week 2 of a group starting at the venue of their choice parents were assigned to the experimental group and undertook the UYCB course. If contact was made after week 2 but more than 10 weeks before the next group was due to start, parents were assigned to the control group, with a view to attending an UYCB group at the beginning of the following term.


During week 1 of the intervention, or the first week after requesting to attend a group, the experimental and control group participants respectively were given: an information sheet, a booklet containing pre-questionnaires and a consent form, and a ‘parent record’ (demographics) form. Participants in the experimental group started the 10-week course.


Following week 1 for the experimental and control group, facilitators (or research team member for controls) checked completed forms. Because the DASS-21 measures elements of the mental health of parents, they were examined within a week of return and advice about local support was given to participants with clinically high scores. 


Upon week 10 participants who completed at least 7 of the 10 available sessions (70%) were invited to complete a post questionnaire booklet. For the control group, a research team member visited consenting parents at home at a time convenient to them to support completion of a post questionnaire booklet. The home visit was intended to increase the likelihood of measures being completed and verify the date of completion. The DASS-21 was checked within a week and again action was taken if necessary. Finally, parents from the control group were offered a 10-week UYCB course. 

Intervention 

UYCB introduces parents to the underpinning theoretical model of containment, reciprocity and behaviour management, with an emphasis on the links between behaviour and emotions, and parental as well as child emotional regulation. In 10x2 hour sessions, it explores issues such as: tuning in to children; exploring feelings; parenting styles; what is being communicated through behaviour; temper tantrums and what might be meant by them; sleep patterns, and behavioural difficulties, see www.solihullapproachparenting.com for session titles. 


Participants attended 96 groups between April 2013 and July 2017, in community venues in two areas of the UK, facilitated by a range of community practitioners (e.g. health visitors, school nurses, community support workers, educational psychologists, social workers, primary mental health workers) trained in the Solihull Approach (2-day Foundation training course) and Parenting Group Facilitator Training (1-day course). Each group was facilitated by 2 practitioners, following a manual outlining the content and delivery methods for each week, with a maximum cohort of 12 parents with similar aged children e.g. 0-4, 5-11 or 11-18 years. The core content of the course remained the same across all the age groups, with practical, age appropriate examples illustrating key principles in action, e.g. role plays and discussion points, provided in the course manual and/or described by facilitators based on their own practice. 

Outcomes

The following questionnaires were selected in order to measure outcomes relating to the child’s behaviour, the adult’s emotional health (stress, depression and anxiety), and changes in the parent-child relationship.

Strengths and Difficulties Questionnaire (SDQ) (Goodman, 1997) 

The SDQ is a widely used, standardised 25-item, brief screening measure for child emotional and behavioural difficulties in 2-17 year olds, adopted commonly in research and clinical useage. Five subscales assess: conduct problems; hyperactivity; emotional symptoms; peer relationship difficulties, and pro-social behaviour. Higher participant scores are indicative of more problems across all scales except for the pro-social behaviour scale where higher scores indicate better functioning.  Good psychometric properties (how valid (accurate) and reliable (consistent) a measure is at capturing what it claims to measure) are reported in the literature (Goodman, 2001) including a systematic review of 48 studies investigating the psychometric properties of the SDQ (Stone et al., 2010). 

Depression, Anxiety and Stress Scale – Short Version (DASS-21) (Lovibond & Lovibond, 1995)

The DASS-21, is a 21-item measure, also widely used and standardised, assessing symptoms of depression, anxiety and stress. Parents rate the degree to which each item applied to them over the past week using a 4-point scale (0=’did not apply to me’ to 3=’applied to me very much/most of the time’). Scores for depression, anxiety, and stress are calculated by summing the scores for the relevant items; higher scores are indicative of poorer wellbeing. 

Child-Parent Relationship Scale – Short Form (CPRS) (Pianta, 1992)

The CPRS is a 15-item scale measuring parents’ perceptions of conflict and closeness in their relationship with their child. The items on the scale were based on attachment theory, the Attachment Q-Set, and observations of parent–child interactions (Driscol and Pianta, 2011). Higher scores on each subscale indicate greater endorsement of perceived conflict and closeness in the parent-child relationship. 

The relationship focus of the theories underpinning the Solihull Approach predicts that the primary outcome of the intervention would be improvements in the relationship between parent and child, with secondary impacts on the child’s behaviour and the parents’ emotional health. The primary measure utilised in this study is therefore the Child-Parent Relationship Scale – Short Form (CPRS) (Pianta, 1992). Two subscales of the SDQ were also of specific interest (measuring ‘prosocial (socially positive) behaviour’ and ‘conduct problems’) as these have previously been found to be associated with the quality of the child-carer relationship (Alexandris et al., 2013).

Secondary outcome measures were the Strengths and Difficulties Questionnaire (SDQ) (Goodman, 1997), and the Depression, Anxiety and Stress Scale – Short Version (DASS-21) (Lovibond & Lovibond, 1995) which were included for comparison with other parenting program efficacy studies in which they are commonly used. 

All three measures are also free and easily available via the internet, the cost and availability of research measures being one of the hurdles to carrying out research, and not onerous for participants to complete.

All three measures were translated into Welsh for use in Wales, and were presented in both English and Welsh in Wrexham.

Sample size 

Mean scores on the CPRS for a UK sample of parents (n=150) have previously been found to be 31.57 (SD = 5.84) for conflict and 32.60 (SD = 2.90) for closeness (n=166) (Simkiss et al. 2013). These were used in the calculation of the required sample size. To be 90% sure of detecting a difference in mean CPRS scores of 1 standard deviation based on Simkiss (2013) at the 5% level (i.e. power = 0.9, β = 0.1, α = 0.05) 42 participants would be needed in each group, or 132 participants at a ratio of 10:1 (120 in one group and 12 in the other). 

To recruit this number of participants a tyear data collection period was anticipated. In reality, control group recruitment was more challenging than expected. The data collection period was therefore extended for a further 18 months until enough participants had been recruited into the control group. 

Data collection stopped at the end of the extension period (coinciding with an additional full year cycle of groups in order to avoid seasonal bias) by which time the control group consisted of sufficient participants (n=26), with 223 in the intervention group. The power of the actual analysis is assumed to be the same as it would be if there were two equal groups with 47 participants in each, based on the harmonic mean of the two asymmetric samples (n = 223,26) of 46.57 (Rankin, 1974). The harmonic mean is a type of average which is sometimes used when calculating ratios.

A one-way analysis of covariance (ANCOVA) was conducted to determine statistically significant differences between the experimental and control groups (independent variable) on responses to the SDQ, DASS-21 and CPRS (dependent variables), whilst controlling for pre-test scores (i.e. the effect of answering the questionnaires). The assumptions required for the ANCOVA were met. 

Results

Table 3 shows means and standard deviations on all measures in the experimental and control groups.

 

 

 

Experimental Group

Control group

 

 

Pre

Post

 

Pre

Post

 

N

Mean

SD

Mean

SD

N

Mean

SD

Mean

SD

SDQ

Total Difficulties Score

181

18.19

7.18

16.22

7.91

20

23.15

6.12

22.35

7.34

Emotional Problems Scale

182

3.68

2.47

3.13

2.46

20

4.05

2.56

4.20

2.75

Conduct Problems Scale

182

4.6

2.63

3.98

2.77

20

6.15

2.06

6.25

2.51

Hyperactivity Scale

182

6.47

2.69

5.94

2.82

20

8.25

1.62

8.05

2.11

Peer Problems Scale

181

3.43

2.06

3.23

2.05

20

4.20

2.42

3.70

2.64

Prosocial Scale

181

6.23

2.15

6.51

2.38

20

4.85

2.21

4.55

2.91

DASS-21

Depression Scale

216

10.33

10.77

7.56

9.36

26

12.88

11.72

11.92

9.45

Anxiety Scale

216

7.38

9.51

5.08

7.26

26

10.92

11.03

10.27

10.94

Stress Scale

216

14.52

10.76

10.71

9.65

26

17.58

9.48

17.23

10.76

CPRS

Conflicts Scale

217

24.02

8.22

22.39

8.21

25

27.40

6.35

27.16

6.99

Closeness Scale

217

28.12

5.21

29.61

4.5

25

29.00

4.89

27.72

5.14

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 3. Showing Means and Standard Deviations (SD) for experimental and control groups


SDQ (Strengths and Difficulties Questionnaire)

After adjustment for pre-test scores, there were statistically significant differences between the experimental and control groups’ post-test scores on the ‘prosocial behaviour’ subscale of the SDQ (F(1, 184)=5.297, p<.05, partial η2=.028) and the conduct problems subscale (F(1, 185)=5.4413, p<.05, partial η2=.029). However neither the ‘total difficulties’ scores (F(1, 184)=1.745, p˃.05, partial η2=.009), nor any other subscale of the SDQ showed statistically significant differences (see table 4).   
 

Variable

F

p

Partial η2

SDQ Total Difficulties

(1, 184)

1.745

.188

.009

SDQ Emotional problems

(1, 185)

2.870

.092

.015

SDQ Conduct Problems

(1, 185)

5.441

.021*

.029

SDQ Hyperactivity and inattention

(1, 185)

2.614

.108

.014

SDQ Peer relationship problems

(1, 184)

0.025

.873

.000

SDQ Prosocial Behaviour Scale

(1, 184)

5.297

.022*

.028

DASS-21 Depression

(1, 223)

3.584

.06

.016

DASS-21 Anxiety

(1, 223)

6.182

.014*

.027

DASS-21 Stress

(1, 223)

8.018

.005**

.035

CPRS Closeness

(1,218)

9.919

.002**

.044

CPRS Conflicts

(1,218)

4.096

.044*

.02

* = significant at p = < .05,   ** = significant at p = ≤ .005,

Table 4. ANCOVA results comparing groups at post condition with pre condition scores as a covariate


DASS-21 (Depression, Anxiety, Stress Scale)

Statistically significant differences were found between the experimental and control groups for the ‘stress’ (F(1,223)=8.018, p<.01, partial η2=.035) and ‘anxiety’ (F(1, 223)=6.182, p<.05, partial η2=.027) subscales of the DASS-21, after adjustment for pre-test scores. Differences for ‘depression’ (F(1, 223)=3.584, p=.06, partial η2=.016) fell just short of significance.  

CPRS-SF (Child-Parent Relationship Scale – Short Form)

There was a statistically significant difference between the groups on both the ‘closeness’ subscale of the CPRS (F(1,218)=9.919, p< .01, partial η2=.044) and the conflict subscale (F(1,218)=4.096, p<.05, partial η2= .02). 
In summary the results indicate improvements, following attendance at UYCB, in parents’ reports of: their child’s prosocial behaviour and conduct problems, closeness and conflict in the relationship with their child, and their own levels of anxiety and stress. It can be concluded that these findings were as a function of attending the group as they were statistically significantly different to the reports of parents in the control group. 

Discussion

The results show that, compared with not attending, attendance at the Solihull Approach group resulted in improvements in: child prosocial behaviour and conduct problems; parental anxiety and stress, and the parent-child relationship (increase in closeness, decrease in conflict), in a cohort that can be considered characteristic of the UK population in terms of ethnicity and those typically attending such groups (majority female). Furthermore, the impact on closeness in the parent-child relationship and parental stress showed highly statistically significant results, with a 99.995% probability that these could not have occurred by chance, see Table 4.

No effects were found on the other child outcomes measured by the SDQ such as hyperactivity, emotional symptoms, peer relationship difficulties, ‘total difficulties’. There was also no statistically significant impact on parental depression. 

The sample consisted of parents who were not necessarily accessing specialist services but had expressed an interest in improving their understanding of their child’s behaviour.

These findings are consistent with previous research (for example Alexandris et al. 2013; Cabral, 2013; Bateson et al, 2008; Vella et al, 2015, Baladi et al., 2018) and confirm that UYCB is likely to benefit the general population. The larger subject numbers and the research design add confidence to previous findings. 

This study brings an RCT design within the scope of clinical departments and charities in the UK who design and implement parenting programmes. Running an RCT can be very expensive, with each one costing over a million pounds and usually far exceeding the cost of developing the programme in the first place! The last decade has seen the elevation of the RCT as the premier research method. Within the field of parenting interventions used in the UK, this has led to the promotion of programmes from the USA and Australia, as they have been able to carry out multiple RCTs, rather than programmes developed in the UK. This method, using time as the randomiser and having the advantage of not imposing an artificial ‘no treatment’ condition on parents, means that programmes developed in the UK have access to another RCT methodology.      

The vast majority of participants in this study were mothers, typical of those attending most parenting groups in the UK (e.g. Cullen et al, 2014). Previous research has found that fathers who attended UYCB were highly appreciative of the experience (Dolan, 2013). Preliminary evidence suggests an increase in closeness and decrease in conflict scores (CPRS) on completion of an online version of UYCB (Johnson, 2018). Further research is suggested to examine the ratio of men to women accessing the online course versus the face to face course, and comparing CPRS scores between genders.

A limitation of this study is the potential bias introduced by the drop-out of participants in the control group, and the ratio of participants in the experimental and control groups. The majority of those assigned to the control group declined to take part in the research study. Therefore, the differences between those who agreed to take part as controls and those who did not are unknown. There were many challenges with securing appointments for data collection, participants not responding to telephone calls, emails or postal correspondence, and not being at home at scheduled appointment times. These reflect the challenges of research in the ‘real world’ in which staying home for someone to ask research questions is not a priority for many parents.

Further weaknesses include the reliance on self-report measures, and the absence of a follow-up measurement point, meaning it is not possible to draw conclusions about the longer-term impact of UYCB. A more robust design would include observational or third-party reporting, requiring practitioners trained in observations of parent-child interactions, and coordination of, for example, teacher reports. This was beyond the scope of the present study and owing to the increased resources required would inevitably result in smaller samples.

Evidence for the efficacy of parenting groups has built over the last two decades (Lindsay and Totsika, 2017; Lindsay, 2019). Now more research is required into what influences parents to take up face to face and/or online programmes.  For instance, the CANparent project (2011-2015), supported by the UK government, aimed to provide parenting classes to at least 20,000 parents; 2926 parents actually accessed the groups (Lindsay et al, 2014), despite up to 55% of (low income) parents expressing a desire to attend (Holloway and Pimlott-Wilson, 2012). There were complications as the (Coalition) government tried to combine making parenting classes available with creating a market in them. ‘The analysis suggests that future government parenting support initiatives would be advised to reflect on the weakness of the quasi-market delivery model’ (Cullen et al, 2017). However, practitioners know it is not straightforward to fill a parenting group, even without such confounding factors. But, even just taking evidence from the Solihull Approach research, it is evident that parents appreciate the courses and benefit from them once they attend. One hypothesis is that whilst there is no stigma attached to antenatal or postnatal classes, there is with other parenting classes. This may be because over the last two or more decades programmes have been targeted at particular parents, so that parents perceive that to attend classes implies there is something ‘wrong’ with their parenting. In some areas parenting groups are offered universally, but there is a big mountain to climb to destigmatise them so that parents see them as interesting and worthwhile in their own right. This could usefully be informed by further research into attitudes of those who do and do not take them up. After all, as this study and others have shown, they do contribute to better regulated, prosocial children and less stressed and anxious adults, and therefore, it can be argued, better life chances for children. What’s not to like?    

Conclusion

Attendance at UYCB was found to result in improvements in parental report and perception of the parent-child relationship, children’s prosocial behaviour and conduct problems, and parental stress and anxiety, in a universal population. The findings are consistent with previous research. There is a case for future research to move in the direction of investigating variables influencing parental take up and ways to destigmatise groups aimed at parents, for the long-term benefit of parents, children and society. 

Acknowledgements

We would like to thank all the parents who participated in this study, the facilitators and organisers of the groups in Solihull and Wrexham. Particular thanks must go to Lisa Baker, Tracy Mansbridge, Catrina Hartle and Flying Start Wrexham, for help with data collection and coordination of the groups. Thanks also to Chris Jones, University of Birmingham, for statistical advice, and to Alex Markham and Rubel Uddin for data inputting and contributing to the analysis.

Study Funding

This work was supported by the Birmingham Hospitals NHS Foundation Trust (formerly Heart of England NHS Foundation Trust) and Wrexham Flying Start.

Conflicts of interest

The authors are employed by the Birmingham Hospitals NHS Foundation Trust in the Solihull Approach department. 


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