Improving accessibility of CAMHS groups within the Orthodox Jewish Community: A service evaluation of an adaptation of the Solihull Approach parenting group, ‘Understanding your child’s behaviour’

11 January 2021

Beth Hill, Ashley Boscoe and Berocha de Lange ask if incorporating spiritual and cultural aspects of Orthodox Judaism into the Solihull Approach parenting group enhances its accessibility and efficacy.

Research summary

  • First Steps Community CAMHS works in the London Borough of Hackney which has the largest Orthodox Jewish (OJ) Community in the UK (Staetsky and Boyd, 2015). 
  • Working in partnership with Koach Parenting, practitioners from the OJ community, First Steps adapted the Solihull Approach parenting group, ‘Understanding your child’s behaviour’, to be inclusive of Jewish cultural values and religious aspects of parenting. 
  • The adapted groups have been piloted with mothers from the OJ community since 2014. This paper aims to evaluate whether adapting Solihull Approach groups to incorporate spiritual and cultural aspects of parenting enabled accessibility whilst retaining efficacy.
  • Fifty-one mothers from the OJ community accepted a place in the groups, with 90% completing the 10-week course over a five-year period. Mothers participating in the groups were asked to complete self-report measures assessing the parent-child relationship (MORS-SF), parental mental health (DASS-21) and to set and rate a parenting goal at baseline and completion. Complete data was collected from 36 mothers.
  • Findings showed a statistically significant increase in warmth, a reduction in parental depression, anxiety and stress, and progress towards parenting goals by the end of the parenting group. There was also a decrease in levels of invasiveness. 
  • The data suggests that the Solihull Approach parenting intervention can be adapted to meet the cultural and religious needs of the OJ community whilst retaining statistically significant efficacy through collaborative community partnerships. Future work could build on these adaptions by forming community links to facilitate the incorporation of spiritual and cultural insights and materials into CAMHS practice.

Hackney’s Jewish population

First Steps is an early intervention community child and adolescent mental health service (CAMHS). The service offers support to children and young people aged 0 to 18 and their families, with mild to moderate mental health difficulties, close to where they live (GP practices and children’s centres) across City and Hackney. This offer includes a range of groups to support parents to understand their children’s behaviour and support their development. First Steps is committed to ensuring that groups are accessible to the diverse communities in Hackney. One hundred and forty-one parents attended First Steps parenting groups between 2012 and 2014 but none of these were from the Orthodox Jewish (OJ) community which comprises 7.4% of Hackney’s total population and over 22% of Hackney’s child population (Mayhew et al, 2011; London Borough of Hackney, 2011).

The Jewish community in Stamford Hill has been established for over 100 years and its membership comprises the largest OJ community in the UK (Interlink Foundation, 2018; London Borough of Hackney, 2018; Baker, 1995). The term ‘Orthodox Jewish’ represents a spectrum rather than a homogenous group but for the purposes of this paper we are referring to those who define themselves as being Charedi, Hasidic and/or Modern Orthodox rather than Reform, United, Liberal or Secular Jews (Rowland, 2016; Spitzer, 2002). 

Children of minority communities are often underserved by mainstream services due to barriers accessing services (Dogra et al, 2012; Elster et al, 2003). Rowland (2016) and Sharman and Jinks (2019) highlight the specific challenges for members of the OJ community due to the importance of religious belief in all aspects of life, the challenge of finding culturally appropriate pathways to help and attitudes to mental health. Indeed, research indicates that OJ families are reluctant to seek help from outside the community and uptake for support is low (Sharman and Jinks, 2019; Frosh et al, 2005). First Steps aimed to offer groups that were not simply targeted at the OJ community but facilitated in partnership with them in order to address these barriers, to take account of the religious and cultural aspects of parenting and to draw from the expertise of colleagues within the community while retaining evidence-based treatment. 

The adaptation process

The process was initiated by conversations with practitioners within the OJ community about equity of training options for voluntary and statutory services within the local Children’s Centre. The outcome of these discussions was a request for a First Steps clinical psychologist to adapt and host the Solihull Approach two-day foundation training for practitioners in the OJ community. Subsequently, a parenting practitioner from the local OJ community partnered with First Steps to adapt and run a pilot parenting group in 2014. Building on this, the parenting practitioner established a charity (Koach Parenting) in 2015 with the aim of using the Solihull Approach to improve the relationship between parents and children within these groups as part of their offer. First Steps and Koach Parenting continued to offer groups annually with one group facilitator from each organisation.  
In order to be in line with recommended evidence-based parenting interventions from NICE (2009) we adapted the Solihull Approach parenting group to incorporate spiritual values and expertise. This group approach was part of First Steps’ standard offer for families with children under five, due to its practicality and robust theoretical structure (Douglas, 2016) and we were aware that Solihull Approach had been adapted for use with other communities by translating materials (Solihull Approach Parenting, 2015).  

In the early stages of the adaptation process, First Steps sought support for the addition of spiritual aspects to the sessions which was provided by the programme’s developer (Douglas, private communication). Koach Parenting met with a local Senior Rabbi who gave approval to run groups with First Steps while maintaining Torah (Jewish law and tradition) values. This partnership between First Steps and Koach Parenting enabled a shared expertise.

Evaluating effectiveness of the Solihull Approach

The Solihull Approach draws on psychoanalytic theory, providing a model for improving the attachment relationship between parent and child and supporting more reciprocal and effective behaviour management (Douglas, 2010). Solihull Approach parenting groups have been shown to significantly increase closeness and decrease conflict within the parent-child relationship (Douglas and Johnson, 2019; Johnson, 2018; Baladi et al, 2018). The groups have also been shown to improve parental wellbeing; Baladi et al (2018) report there was a significant decrease in parents’ self-reported depression, anxiety and stress from baseline (session one) to group completion (session 10).

Previous literature emphasises the importance of evaluating the efficacy of parenting interventions beyond anecdotal reports of parent satisfaction (Cabral, 2013). It is also acknowledged that within a busy NHS setting, evaluating interventions can be a difficult task, often due to lack of time and resources (Bateson et al, 2008). This study aimed to use validated outcomes that measure constructs relevant to attachment, parenting and parental wellbeing in line with the aims of the Solihull Approach parenting groups. 

Cultural adaptations can be tokenistic or result in communities being offered a one-off tailored workshop, limiting access to evidence-based interventions. Early attempts at culturally adapting evidence-based parenting interventions have focused on changes to video/image components of the programme (Kumpfer et al, 2002). Some research suggests that cultural adaptions could be more effective if more structural modifications are made that address cultural identity, values and practices (Resnicow et al, 2000). However, there is limited research evaluating whether such changes will significantly improve outcomes in addition to accessibility and up-take of support (Kumpfer et al, 2002). This study aimed to address this. 

Shared expertise shaping content

The OJ community tends to have larger than average families, with an average six to seven children per couple (Institute of Jewish Policy Research, 2016). Group discussions thus covered a broader range of developmental stages to account for children of different ages and the opportunities and challenges of larger families. In addition, Sharman and Jinks (2019) found that religion of the therapist and language around therapy were a significant factor for members of the community accessing services and it felt important that one of the facilitators had experience of growing up in and parenting a family of this size within the local community. 

In particular, the use of expertise and knowledge of the importance of Torah values as defining all aspects of life (Loewenthal and Rogers, 2004), enabled the development of supplementary materials concerning spiritual life, termed ‘Torah Thoughts’. As it is important religiously to keep separate from some aspects of mainstream culture (Hakak, 2011), some of the materials were amended to make them suitable to discuss within a group context for example: references to teenagers ‘going out’ were removed from developmental milestones as there are no physical relationships with the opposite gender, unless closely related. 

Furthermore, careful consideration of experiences of antisemitism and trauma was required when facilitating sessions that address transgenerational parenting given the fact many of the community are second- and third-generation Holocaust survivors.  

In order to ensure that participants and their children felt comfortable accessing the group, an OJ community venue (Lubavitch Children’s Centre) that employed qualified crèche workers from the OJ community was chosen to host the programme. As it is deemed inappropriate for men and women to mix socially outside of family or work contexts, groups for mothers and fathers were run separately. This paper reports on the groups run with mothers, because at the time of writing more of these have been completed.

Aims of the service evaluation:

  • to increase the number of mothers from the OJ community accessing groups for parents
  • to evaluate whether incorporating spiritual and cultural aspects of parenting retains the intervention efficacy found in other studies of the Solihull Approach parenting groups (improved parent-child relationship and parental wellbeing).  

Our hypotheses are as follows:

H1 There will be a statistically significant decrease in parental depression, anxiety and stress after completion of the parenting group.  

H2 There will be statistically significant progress made towards parenting goals after completion of the parenting group.

H3 There will be a statistically significant increase in mother’s perceptions of their children’s levels of warmth after completion of the parenting group.

H4 There will be a statistically significant decrease in mother’s perceptions of their children’s levels of invasiveness after completion of the parenting group.


Recruitment and procedure

The group was offered to mothers from the OJ community who were accessing First Steps CAMHS. Mothers were also able to self-refer to the group, advertised through accessible children’s centres and local Orthodox Jewish newspapers. Mothers interested in accessing the group were placed on a waiting list and invitation letters offering a description of the group were sent to them by post.  

Mothers who accepted a place attended the 10-week adapted version of the manualised Solihull Approach ‘Understanding Your Child’s Behaviour’ parenting group for parents of children aged 0-18 years, supplemented by ‘Torah Thoughts’. 


Fifty-one mothers from the OJ community accepted a place in a group. Of these, 46 participants completed the course (90%). Mothers that attended identified a referred child for the purposes of the questionnaires and complete data was recorded for 36 mothers. There were approximately 42% boys and 58% girls aged between 0 and nine years (approx. 72% aged between 0-5 years and 28% aged 6-9 years).


This project has been assessed to ensure it meets the required criteria for a service evaluation by Homerton University Hospital NHS Trust Research and Development Department who recommended service evaluations are part of quality assurance. All data is stored securely on the NHS shared drive and no identifiable information is shared in the dissemination of this evaluation. Mothers who attended the group were given an explanation about the purpose of completing questionnaire-based outcomes, including the potential dissemination of their anonymised scores.


Mothers were asked to complete the outcome measures in session one and then again in session 10. 

The Depression, Anxiety and Stress Scale (DASS-21) is a 21-item measure consisting of three subscales assessing depression, anxiety and stress (seven items per subscale). Items are presented as a statement with four possible response options from zero (did not apply to me at all) to three (applied to me very much, or most of the time). In order to calculate a total score comparable with the full version of the DASS, the total score of each subscale is multiplied by two (Lovibond and Lovibond, 1995) and ranges from 0-42. The measure has good psychometric properties and good internal consistency with Cronbach’s alpha of .88 for the overall scale (Tran et al, 2013). 

Goal Based Outcomes (GBOs) are idiographic outcome measures that are used to evaluate progress towards goals in clinical work with parents and young people. These were included to capture clinical evaluation of mothers’ hopes in attending alongside measuring efficacy in domains identified by the literature. In this instance, they compared progress towards reaching a chosen parenting goal set at the beginning of an intervention compared to after completion using a numerical scale from 0-10. Change is measured by the amount of movement along the scale at two time points with a suggested reliable change index of 2.45 (Jacob et al, 2015).

The Mother’s Object Relations Scale Short Form (MORS-SF) is a 14-item questionnaire assessing mother’s working models of attachment and relationship with their infants across two axes; emotional warmth-coldness and invasion-withdrawal of the infant towards the mother (Oates et al, 2018). The measure has good psychometric properties and good internal consistency, Cronbach’s alpha for warmth is .75 and .81 for invasion (Oates et al, 2018).

Design/data analysis 

A pre-post, within-participant, quantitative design was implemented for this study. Existing anonymised quantitative data collected as part of routine outcomes monitoring protocol was used to compare change on three outcomes measures across two time points (baseline and completion). 

An exploratory data analysis was carried out and the findings suggested the data was suitable for parametric analysis. Paired samples t-tests were carried out using SPSS version 24.


Descriptive data of parenting group attendance were collated to compare changes in accessibility for the OJ community upon the introduction of the adapted group in order to assess whether we met our aim. Audit data in 2012-2014 showed that there were no parents from OJ community accessing Solihull Parenting groups prior to adaption. 

Between 2014 and 2018, there was an increase from 0 to 51 mothers from the OJ community accepting a place in a group with 46 completing the adapted course (90%). Comparisons were made with average completion rates for the standard Solihull group offer in First Steps over the five-year period (see Table 1). This showed that the adapted Solihull Approach group had higher than the average completion rates each year. The audits show a 68% (75 out of 114) completion rate for the standard Solihull Approach Parenting with a 90% (46 out of 51) completion rate for the group adapted for the OJ community from 2014-2019 (Harding, 2019; Harding 2014).  

A paired samples t-test was conducted to compare the questionnaire scores at the start of the group (baseline) with scores at the end of the group (completion). Statistical comparisons were made to measure the difference in mean scores of the DASS-21 (H1), the Goal Based Outcomes (H2), and the MORS-SF subscales; warmth (H3) and invasiveness (H4). Please see Tables 2 and 3 for mean scores on the different outcome measures and t-test data, respectively. 

Parental depression, anxiety and stress

There was a statistically significant decrease in total scores on the DASS-21 at completion (M=11.29, SD= 11.09) compared to baseline (M=15.81, SD=12.73), t (35) = -3.686, p= .001, d=.379 with small effect size. The mean scores on individual subscales of depression, anxiety and stress were statistically analysed to evaluate whether there would be a significant decrease in one or more subscales. After applying a Bonferroni correction for multiple comparisons, there was no statistically significant (p<.007) decrease in scores from baseline to completion on the specific subscales of the DASS-21; Depression:  t (35) =-2.683, p= .012, d= .356, Anxiety: t (35) =-1.936, p= .061, d= 0.278 and Stress: t (35) =-2.830, p= .008, d=.305. See Table 3. 

These data suggest that the mothers attending the group showed a statistically significant decrease in total difficulties in depression, anxiety and stress, rather than in specific areas measured by the subscales. These findings indicate that we can accept our first hypothesis that there would be a statistically significant decrease in parental depression, anxiety and stress after completion of the parenting group.

Goal Based Outcomes

There was a statistically significant difference between goal ratings at completion compared to baseline, t (14) =-7.447, p= .000, d= 1.741 with a large effect size (Cohen, 1988). The mean scores indicate that the mother’s goal ratings at completion (M=19.33, SD= 6.13) were significantly greater than their goal ratings at baseline (M=10.13, SD=4.27), which suggests that those who attended the group made statistically significant progress towards their parenting goals upon completion of the intervention. This is greater than the 2.45 increase which indicates reliable change (Jacob et al, 2015). These findings suggest we can accept our second hypothesis that there would be statistically significant progress made towards parenting goals after completion of the parenting group.

Mothers’ perceptions of their infants’ warmth and invasiveness

There was a statistically significant increase in levels of mothers’ perception of their infants’ warmth after completion of the group (M= 28.19 SD=4.798) compared to baseline (M=23.94 SD=6.727), t (35) = 4.788, p= .000, d= .727, with a medium effect size (Cohen, 1988). This suggests we can accept our third hypothesis that there would be a significant increase in mother’s perceptions of their children’s levels of warmth after completion of the parenting group.

There was also a decrease in levels of invasiveness at completion (M=13.86 SD= 5.991) compared to baseline (M= 16.39 SD=6.258), t (35) =-2.199, p= .035, d=.413. However, after applying Bonferroni’s correction for multiple comparisons, this finding was not statistically significant to p<.007. This suggests we must reject our fourth hypothesis, that there would be a statistically significant decrease in mothers’ perceptions of their children’s levels of invasiveness after completion of the parenting group.

Table 1: Adapted Solihull Approach parenting group participation from 2014 to 2018



Table 2: Mean and standard deviation of parents’ scores on the MORS-SF, DASS-21 and GBOs at baseline and completion


Note: M = Mean, SD = standard deviation, N = sample size 


Table 3: Paired sample t-test comparing parents’ scores on the MORS-SF and DASS-21 at baseline and completion of the group


Note: Estimations of effect size are calculated using Cohen’s d. 
*statistically significant after applying Bonferroni correction for multiple comparisons t p<.007.




One of the aims of this project was to improve accessibility while retaining the efficacy of the Solihull Approach parenting group. The well-attended groups and 90% completion rate consistently over the course of five years suggests this aim was met. In addition, internal audits indicate that such completion rates are higher than in the standard groups that First Steps offers (Harding, 2019; Harding, 2014). The implication may be that completion rates for parenting groups are enhanced by introducing culturally and spiritually relevant adaptions and could be considered with other communities. 

Efficacy of the adapted group

In line with the literature evaluating the non-adapted Solihull Approach group (Baladi et al, 2018; Bateson et al, 2008), there was a statistically significant reduction in parental depression, anxiety and stress with a small effect size (Cohen, 1988). The adapted group also enabled statistically significant progress towards parenting goals with large effect size and with mean ratings indicating reliable change. 

Previous researchers have found that both face-to-face and online versions of the Solihull Approach course increased closeness and decreased conflict within the parent-child relationship (Douglas and Johnson, 2019; Johnson, 2018; Baladi et al, 2018). These findings of a statistically significant increase in mothers’ perceptions of children’s levels of warmth (with a large effect size) indicate potential improvements within the parent-child relationship as a result of attending the adapted group. However, we did not find a statistically significant decrease in mother’s perceptions of their children’s levels of invasiveness within this population.

Overall, the findings suggest that parenting groups with culturally relevant adaptations could increase accessibility and could enable statistically significant change across the domains of mother’s wellbeing, progress towards parenting goals and mother’s perceptions of their children’s levels of warmth. This contributes to an evidence base for the efficacy of this culturally adapted version of the Solihull Approach parenting group. The authors are not aware of other Solihull Approach parenting groups that have been adapted in this way, so our findings are encouraging for other potential projects.

Strengths and limitations

Cabral (2013) highlights the importance of evaluating the efficacy of parenting interventions beyond anecdotal reports of parent satisfaction. This study is strengthened by its quantitative design which seeks to substantiate the reported benefits of parenting interventions and aims to contribute to empirical literature. In addition, the data has been collected over five years, which increases the ecological validity of the findings. 

While we saw an improvement in accessibility and the group was accessed by mothers from different subgroups within the community, some mothers invited to attend chose not to. We are mindful that some community members may still find engagement with CAMHS difficult and their experience is not represented here. First Steps and Koach Parenting hope to continue to learn from community members about their experience of using services to ensure accessibility to all. In addition, this study focuses on groups for mothers so this paper is limited in not evaluating fathers’ perspectives on CAMHS groups. First Steps and Koach Parenting aim to evaluate the ongoing fathers’ groups in the future. 

Participants whose first language was not English reported finding some of the terms in the evaluation measures difficult and some mothers reported that they did not wish to complete the questionnaires. A number of partially completed forms could not be included in the evaluation and it is unclear whether there were any patterns in those who did not complete the forms. Validated measures were used; however, a limitation of this study was the reliance on self-report measures. Furthermore, the final sample was relatively small (n=36) and there was no follow-up to measure whether changes were maintained over time.

Implications and recommendations

This service evaluation indicates that structural modifications to address spiritual and cultural identity can be made while retaining the efficacy of an evidence-based parenting group. This project demonstrated that NHS services working in collaborative partnership with local communities can offer an intervention which increases accessibility and facilitates statistically significant change for mothers. Listening to the concerns of local families and working in partnership with community practitioners enabled us to understand the importance of Torah values for shaping all aspects of life. The adaptations necessary to incorporate these principles into the Solihull Approach Parenting group were only possible through partnership working.  

This process of adaptation involved considerable time commitment from both parties. Where NHS services and charities are working with limited resources, this can be a challenge. In this instance, the strong ties between NHS services and communities have been built over time through building trust in relationships and using a community psychology approach (Orford, 1992). This involved learning together, researching spiritual resources, seeking advice from others and continually learning from the feedback of mothers attending the group. This has been an intensive, effortful process but has ensured relevance, efficacy and has also enhanced the practice of both parties. 

Given the statistically significant impact of the group, we recommend continuing to work in partnership to continue to offer the adapted Solihull Approach parenting group to the OJ community. In order to sustain this offer, more community members are currently being trained in the Solihull Approach and becoming involved in the group facilitation. The service continues to acknowledge that each group’s spiritual and emotional insights help shape the adaptions of the next.  

The increased accessibility and efficacy of an adapted Solihull Approach parenting group demonstrates the feasibility of taking the time to make the adaptations. Our experience has highlighted the value of incorporating spiritual aspects of life into a parenting group for some communities; we would therefore recommend other services consider this in offering groups for specific communities. Building on our learning and in continued partnership with Koach Parenting, First Steps is beginning to work with the local Imam and colleagues to adapt the Solihull Approach parenting group with supplementary materials inspired by Qur’anic teaching with the aim of running an adapted group within the local mosque.


This service evaluation showed increased access, significantly improved maternal wellbeing and some significant improvements in the parent-child relationship. We recommend that the adapted Solihull Approach parenting group continues to be offered to the OJ community. It also shows us that strong ties between NHS services and local communities are of paramount importance when offering culturally appropriate interventions. We recommend other services consider incorporating spiritual and cultural insights and materials into their practice. 

Dr Beth Hill is clinical psychologist and Ashley Boscoe is assistant psychologist at First Steps Early Intervention and Community Psychology Service, Homerton University Hospital NHS Foundation Trust; Berocha de Lange is parenting practitioner at Koach Parenting. 

Research Funding

This piece of research was funded internally within First Steps Early Intervention & Community Psychology Service, Homerton University Hospital NHS Foundation Trust, as part of service development and evaluation. 


We would like to acknowledge the mothers who have participated and whose insights helped shaped these adaptions. We also want to acknowledge Rabbi Daniel de Lange who helped adapt the materials and Lubavitch Children’s Centre, which hosted our groups and provided crèche facilities. Thanks also go to Dr Jo Temple and Naomi Freeman who also ran adapted groups for the community in 2015. Thanks to Maria Mateen, Rachel Ransley and Susie Haynes whom during their time at First Steps helped with data collection. We appreciate Hazel Douglas’ openness to us attempting this challenge with the Solihull Approach group materials and Rebecca Johnson for reviewing a draft of this paper.


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