Parent training for dependent, yet abled, young adults

Uri Berger, PhD 

Eli Lebowitz, PhD 

The term Failure to launch (FTL) has been used to describe abled  adults who do not work, do not attend school, and live with— and at the expense of—their parents. FTL can be beneficially  addressed through parent training, a treatment method that is  rarely used with adults (i.e., individuals past the age of majority).  The authors first review the goals of parent training programs  offered to parents of adults. The review demonstrates that these  goals dovetail with key aspects of FTL. The authors then describe  a new parent training approach for parents of individuals with  FTL, based on SPACE (Supportive Parenting for Anxious Child hood Emotions). They highlight five key components of SPACE FTL: Psychoeducation, Reducing Parental Accommodation,  Increasing Parental Support, De-Escalation, and Engaging Sup porters. The authors conclude by discussing SPACE-FTL in rela tion and comparison to other parent training programs and their  components. (Bulletin of the Menninger Clinic, 86[3], 249–281) 

Keywords: failure to launch, accommodation, parent training,  anxiety, young adults 

For young adults (YA) who do not work, do not attend school,  and live with—and at the expense of—their heavily burdened  parents, the natural transition to adulthood can be a grim “fail ure to launch” (FTL). The term FTL is used for the remainder of  this article, although the phenomenon goes by other names (e.g.,  Hikikomori, Bamboccioni, Tanguy syndrome, boomerang kids).  Furthermore, FTL is used here for the sake of brevity, without  

judgment and in a nonpejorative, descriptive way. Failing to launch poses a severe risk to millions of Americans  (e.g., DeSilver, 2016), and numbers have risen since the onset  

Both authors are with the Anxiety and Mood Disorders Program, Child Study Center,  Yale University, New Haven, Connecticut. 

Correspondence may be sent to Uri Berger, Child Study Center, Yale School of  Medicine, 230 S. Frontage St., New Haven, CT 06520; e-mail: uri.berger@yale.edu  (Copyright © 2022 The Menninger Foundation)

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of COVID-19 (Fry, Passel, & Cohn, 2020). Time spent in FTL  is detrimental to future independence and mental health (Kato,  Kanba, & Teo, 2019; Ralston, Feng, Everington, & Dibben,  2016). Furthermore, the COVID-19 pandemic has had two sig 

nificant FTL-related effects on the YA population. First, many  YA lost their jobs (Falk, Carter, Nicchitta, Nyhof, & Romero,  2021). Second, the already high percentage of YA living with  their parents has further increased in this time period (Fry et al.,  2020). FTL is not only a personal and familial problem; it is also  a major societal problem. Individuals with FTL do not work or  pay taxes, thus decreasing the country’s gross domestic product.  Therefore, developing and providing therapeutic solutions for  individuals and families coping with FTL is imperative.  

We and others have found that FTL can be beneficially  addressed through parent training (PT) (Dulberger & Omer,  2021; Kubo et al., 2020; Lebowitz, 2016; Lebowitz, Dolberger,  Nortov, & Omer, 2012). The present review briefly reviews the  goals of PT programs offered to parents of YA. The review dem 

onstrates that these goals dovetail with key aspects of FTL. The  second section describes our PT approach and its key compo nents. We conclude by discussing this approach in relation to  other programs and their components. 

Parent training for parents of YA 

PT is a form of psychosocial intervention based on the premise  that a child’s mental health can be improved by changes in the  behavior, thoughts, and communication of the child’s parents.  For example, PT is efficacious and commonly used in the treat 

ment of disruptive child behaviors (Lundahl, Risser, & Lovejoy,  2006), children’s attention-deficit/hyperactivity disorder (Lee,  Niew, Yang, Chen, & Lin, 2012), and child anxiety disorders  (Lebowitz & Majdick, 2020; Lebowitz, Omer, Hermes, & Sca 

hill, 2014; Lebowitz, Panza, & Bloch, 2016; Lebowitz & Shim shoni, 2018; Lebowitz et al., 2013). Despite the efficacy of PT,  there is a sharp decline in its use once children reach young  adulthood. One reason is that young adulthood is characterized  by growing independence from one’s parents (Seiffge-Krenke,  Overbeek, & Vermulst, 2010). Nonetheless, parental support  remains essential for YAs’ well-being and successful adaptation 

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to adulthood (Demir, 2010; Shulman, Kalnitzki, & Shahar,  2009) and PT programs for YA have been developed and tested.  Reviewing studies on PT programs for YA reveals certain  

shared goals that make such programs relevant for this popula tion (for details on our review process and methodology, see  our Open Science preregistration: 10.17605/OSF.IO/BNAFU).  One goal of PT programs for YA is to assist the YA in overcom ing mental health problems. Parents can be trained to directly  impact the YA’s symptoms, or to modify elements of their own  behavior that may be indirectly maintaining or exacerbating the  YA’s condition. For example, in a study of YA with anorexia  nervosa, parents were instructed on managing eating behavior  at home (Whitney et al., 2012). In addition, parents were aided  in reducing their guilt, increasing their confidence in their ability  to help the YA, and reducing problematic family interactions.  Similarly, substance-related problems and addiction in YA have  also been treated with PT that aims to reduce substance use  (e.g., Grossbard et al., 2010; Miller, Meyers, & Tonigan, 1999;  Smeerdijk et al., 2015). Other PT programs aim to improve the  general health and well-being of the YA, rather than to treat spe cific symptoms or disorders (e.g., encourage weight loss; Curtin  et al., 2013; Myers et al., 2018). 

Another goal of PT programs is helping parents to promote  more independent functioning in the YA. For example, a pro gram provided to parents of YA with autism spectrum disorder  focused on reducing services provided by the parents, resulting  in increased independence (Golan, Shilo, & Omer, 2018). In one  study by DiPipi-Hoy and Jitendra (2004), parents of YA with  intellectual disabilities were trained to teach their children pur chasing skills in a community setting. In other programs, par ents of YA are trained to support their children in the transition  to adulthood (e.g., teaching the YA to create daily life routines,  using nonfamilial support, and informing the YA about their  legal rights; Yildiz & Cavkaytar, 2020). Independence can also  be promoted by parent-focused training. These include teaching  parents their own rights and how to empower themselves (e.g.,  Burke, 2016; Paswan & Kumar, 2021). 

PT can help parents of YA with physical disabilities transition  from adolescent care to adult care (e.g., Allen, Scarinci, & Hick son, 2018). This transition is often complicated by YA assuming 

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the legal responsibility for their own healthcare and medical  information (Koepke & Denissen, 2012), while also often rely ing on continued parental involvement (Heery, Sheehan, While,  & Coyne, 2015). Finally, it has been shown that PT can decrease  dangerous behaviors. For example, PT was effective in reducing  YA drivers’ unsafe driving behavior (Farah et al., 2014), and PT  for parents of college students was shown to reduce high-risk  

sexual behaviors and substance use (Cooper et al., 2020). In summation, reviewing the relevant literature reveals that  PT has been applied with YA in a variety of contexts in which  the YA’s transition to independent adult life is compromised  by physical or mental health conditions and places significant  burden on parents (e.g., Lindgren, Söderberg, & Skär, 2016).  Parents who are highly involved in the YA’s life and who are  experiencing such burden may be particularly motivated to  engage in PT. Reducing parental burden may be one reason for  findings indicating that PT can have a positive effect on the par ent’s own well-being (e.g., Rutherford et al., 2019).  The above review highlights commonalities between the  goals of PT programs for YA and the features of FTL. First,  there are indications that individuals with FTL suffer from  various psychiatric disorders such as anxiety (e.g., Lebowitz &  Omer, 2013) and that these disorders may contribute to FTL  (Kato et al., 2019). Second, the hallmark of FTL is the failure  to achieve independence as an adult (Dulberger & Omer, 2021;  Lebowitz, 2016; Lebowitz et al., 2012; McConville, 2021). YA  with FTL and their parents are caught in a cycle where attempts  by either child or parent to promote independence can exac erbate the situation and further increase dependency (i.e., the  dependency trap; Lebowitz et  al., 2012; Lebowitz & Omer,  2013). Finally, FTL can contribute to significant frustration and  burden for parents (Berger & Lebowitz, In preparation). One  conclusion is that PT may be usefully implemented with parents  of YA coping with FTL. 

SPACE-FTL: A parent training program for YA with FTL 

Our PT program for YA with FTL derives from a parent based treatment for anxious youth called SPACE (Supportive  Parenting for Anxious Childhood Emotions). SPACE has been 

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repeatedly tested and found to be efficacious in several trials  (Lebowitz & Majdick, 2020; Lebowitz et al., 2014; Lebowitz  & Shimshoni, 2018; Shimshoni, Silverman, & Lebowitz, 2020),  including a randomized controlled trial with 124 children with  primary anxiety disorders that showed noninferiority of SPACE  relative to individual cognitive-behavioral therapy (Lebowitz,  Marin, Martino, Shimshoni, & Silverman, 2020). 

SPACE-FTL is suitable for parents of adult children who are  seemingly able (i.e., the adult child has not suffered a major  injury or disease) but are not engaged in higher education or  gainful employment. In most cases, the adult child lives in the  parents’ home or is supported by the parents. SPACE-FTL  includes weekly parent sessions. Sessions can be conducted  in-person or online via a video conferencing application. The  sessions include psychoeducation, training on specific strate 

gies, and role-play. Following some sessions, parents are given  specific tasks to complete at home between sessions. SPACE FTL focuses on reducing parental accommodation of the YA’s  lack of function, and on developing and implementing plans for  increasing their functional independence (see expanded descrip tion below).  

Both parents are encouraged to participate (when relevant),  although treatment can also be implemented with only one par ent. SPACE-FTL has not been tested, and may be less appli cable, when the adult child has a major mental illness such as  psychotic disorder, bipolar disorder, autism spectrum disorder,  or significant intellectual delay, or when they have serious addic tion or substance problems. Likewise, SPACE-FTL may not be  feasible or sufficient when the adult child shows signs of acute  suicidality requiring a higher level of care. 

Components of SPACE-FTL 

This section describes and illustrates the key components of  SPACE-FTL. Although these components derive from the origi nal SPACE protocol for youth anxiety, working with parents  of YA with FTL creates unique challenges. As will be discussed  below, parallels to many of these components can also be found  in other PT programs for YA. 

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Psychoeducation 

Psychoeducation in SPACE-FTL helps parents to understand  their adult child’s lack of independence, to develop a construc tive function-oriented attitude that emphasizes acceptance of  mental health problems rather than focusing on the YA’s per ceived character flaws, and to facilitate the parent’s treatment  adherence by promoting realistic expectations and providing  the rationale for SPACE-FTL. 

Many parents of YA with FTL begin the process of treat ment with only very partial awareness of the YA’s mental health  symptoms that may be contributing to their lack of indepen dence. This can be due to the YA not having been open in the  past about their struggles. In other cases, a family style that  promotes alternative explanations for the child’s problems can  hamper clear understanding of mental health problems (e.g.,  assuming that college professors have simply misunderstood  the YA). Some parents will be aware of certain problems (e.g.,  attention-deficit issues that were diagnosed through school test ing) and assume that all current issues must necessarily stem  from the same diagnosis, an assumption that may be factually  incorrect but is easier for parents to contend with than accept ing that other psychiatric issues may also be at play. 

Parents who attribute their child’s behavior to personality  traits or character flaws such as “laziness” or “selfishness” will  often benefit from psychoeducation that reframes the prob lems in the context of actual “real” problems, allowing them to  develop a less negative or hostile approach to the YA. 

Another topic for psychoeducation relates to the legal status  of YAs and parents’ formal obligations toward them. When chil dren reach the age of majority, parents’ legal guardianship (i.e.,  child custody) is terminated, and the parent is no longer obli gated (by law; with some specific exceptions) to provide for the  child. Consequently, the relationship is defined as “voluntary”  instead of obligatory. This change is not always understood by  parents, especially because the change in legal status does not  “fit” their perception of the actual relationship. Understanding  this change through psychoeducation is instrumental in helping  parents to view the various resources they provide to the YA  as voluntary, freeing them to make informed decisions about 

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which resources are useful in promoting function and which  may actually be maintaining the FTL status.  

Case vignette 1: Psychoeducation 

Johnny¹, age 22, lived with his parents and spent his days sleeping  and nights playing online games. He brushed off any attempts  by his parents to get him a job or his own apartment. Johnny’s  parents were aware of his learning difficulties, diagnosed in high  school, but these did not seem to explain his post–high school  lifestyle. At the start of treatment, both parents indicated that  they perceived Johnny as a “lazy parasite” who would do noth 

ing for anyone but himself. Johnny’s remarks to his father about  giving him the money he had been saving for his retirement  dream boat only made things worse.  

The therapist addressed these negative perceptions: “You’ve  become used to thinking of Johnny as lazy. When we say some one is lazy, we usually mean it in a pretty negative way, to  describe someone who actually enjoys being able to avoid doing  things. You may feel resentment and anger toward Johnny for  not getting his act together and getting on with his life, and you  may believe he enjoys his current lifestyle. I’m pretty sure that is  not the case at all. I don’t think Johnny is actually lazy, or that  he is enjoying this situation. In fact, it’s much more likely that  Johnny is experiencing a real difficulty and is deeply unhappy  about it.”  

After the therapist explained how anxiety drives avoidance,  the mother asked, “Well, this is all fine, I get it that he has a  problem, but why doesn’t he do something about it?!” The  therapist then explained that healing can be a challenging and  painful task that Johnny tries to avoid much as he avoids other  major hurdles. The therapist also explained: “Usually, avoid 

ance of real-life situations will result in boredom and loneliness.  However, in the present state, Johnny is able to get through his  days without constantly feeling that boredom and loneliness,  because online platforms provide a lot of stimulation and inter 

actions. Furthermore, while lonely people normally still need to  

1. Any personal information that could identify treated individuals was removed or  changed.

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go to work and provide for themselves, Johnny does not have  to do that because his needs are being met at home.” In this  way, the therapist was able to reduce the negative hostility that  permeated the parents’ attitudes toward their son, while also  helping them to see that the resources they had been providing  might actually be counterproductive to their son’s independent  functioning. 

As the parent training progressed and the parents’ behav ior started to change, Johnny had a hard time acclimating to  the changes his parents were making and he became enraged.  Johnny wrote his parents a very long text message describing  many grievances, among which was a complaint that “you treat  me like a child, stop that! I am an adult with equal rights, just  like you!” The father fired back a text, saying, “In this house,  there are children and parents! And we all have our role! So, we  are not equal!!!” At this time, the therapist discussed with the  parents how their legal status had changed with regard to their  adult son. The parents expressed surprise and the father said,  “But he is our child! Don’t we have right as parents?!” Clari 

fying, the therapist said, “Johnny is technically correct. He is  your equal, just like your next-door neighbor. However, neither  Johnny nor your neighbor has rights to your property or money.  Only you have the right to make decisions about how you spend  your money.” The parents gradually shifted their view, and a  few sessions later the father commented, “I realized that once  Johnny turned 18, he became a guest in this house, and unlike  children, guests—no matter how much you love them—are  there by invitation”. 

Reducing parental accommodation 

Parental accommodation refers to changes in the behavior of  parents of children with psychological problems, aimed at pre venting or reducing the child’s symptom-related distress. For  detailed reviews of the research on parental accommodation,  see the following sources: Norman, Silverman, and Lebowitz,  2015; Shimshoni, Omer, and Lebowitz, 2022; and Thompson Hollands, Kerns, Pincus, and Comer, 2014. In brief, research  on accommodation (most of which focuses on accommodation  of anxiety and related problems) shows that parents almost 

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always respond with accommodation to their child’s symptoms.  Although well-intentioned and potentially effective in reducing  distress in the short term, accommodation can actually exacer bate and maintain children’s symptoms and related impairment  (Jones, Lebowitz, Marin, & Stark, 2015; Lebowitz et al., 2016;  Storch et al., 2015). Reducing accommodation via PT has been  shown to reduce childhood anxiety (Lebowitz, 2019; Lebowitz  et al., 2016; Lebowitz et al., 2013) and is central to SPACE, the  treatment upon which SPACE-FTL is based.  

Dependent behaviors by YA and accommodating behaviors  by their parents can take numerous forms (See Table 1; adapted  from Lebowitz et al., 2012). For example, YA may demand that  the parents act as go-betweens between them and others (e.g.,  waiters, physicians, other family members), and the parents may  accommodate by providing such moderation.  

YA with FTL often rely heavily on their parents for accom modation. Indeed, the difficulties experienced by YA with FTL,  paired with repeated accommodation by parents, has been  termed a “dependency trap” (Lebowitz et al., 2012; Lebowitz &  Omer, 2013). Families become ensnared in a dynamic where the  FTL child is distressed and demands increasing accommodation  from parents, while the parental accommodation undermines  the YA’s function by making nonfunction easier and more com fortable. Sporadic or impulsive attempts by parents to withdraw  the accommodation can lead to acute distress or aggressive  outbursts, ultimately leading the parents to resume, and even  increase, the accommodation, and to even poorer independent  function in the adult child. 

Systematically reducing parental accommodation is a central  element of SPACE-FTL. Significant time is dedicated to helping  parents identify the ways in which they have been accommodat ing, and to gradually decrease the accommodation. Reducing  parental accommodation triggers a critical shift in the choice  facing the YA on a daily basis. Rather than having to choose  between taking seemingly daunting steps toward function or  comfortably persisting in their lack of function, the YA now faces  a choice between taking small steps forward toward improved  function, or not taking those steps and coping with the discom 

fort of the reduced parental accommodation. Guiding parents to  reduce accommodation requires time and creativity to overcome 

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Table 1. Dependent behaviors by young adults and accommodating behaviors by their parents 

Dependent Behavior by YA Accommodating Behavior by Parent ^{Demands for housing and equal right in par} _{ents’ property.}Letting the young adult live at home or paying  

for his/her housing. 

_{goods, or services.}Supply of money, goods, or services. Explicit or implicit demands for money,  

Demand for continuous reassurance, either  ^{verbal (e.g., numerous phone calls through} out a day) or physical (e.g., constant checking  for parent’s presence). 

Providing continuous reassurance (e.g., by  being continually present or available). 

_events.Feeling and expressing guilt for being a bad  

Blaming the parent, in general and for daily  

^{Use of parent as a go-between and modera} tor for communicating with anyone but the  parent (e.g., waiters, physicians, other family  members). 

Maintaining a paradoxical, “present yet  alienated” attitude toward the parents: “I am  here all the time, but I will reduce contact to  a minimum.” 

Demanding secrecy about one’s condition;  expressing discontent when the parents share  anything about the YA situation. 

parent. 

Acting as go-between or moderator. 

^{Accepting young adult’s presence while avoid} ing contact. ^{Maintaining secrecy (e.g., not sharing informa} tion about the young adult or lying to others). 

^{future goals (e.g., claiming to work on a You} _{Tube channel).}Cooperating with the young adult’s illusion of  

Maintaining an illusion of function and  Note. Adapted from Lebowitz et al., 2012.

function and future goals (e.g., telling friends  and family of the young adult’s project). 

challenges and obstacles. For example, certain resistance can be  expected from the child who has become accustomed to relying  on the accommodation to avoid anxiety. Resistance may also  come from the parent, who may feel guilty or anxious about  reducing the accommodation.  

Case vignette 2: Reducing parental accommodation 

Rachel, age 23, was living with her parents and her younger  sister. She was a brilliant young woman but had not been able  to advance beyond a high school education apart from brief  attempts to attend the local community college. Rachel spent  most of her time playing online games. Rachel’s parents were  very concerned. They felt the financial burden of feeding another  person and heating another section of their house. In addition,  

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Rachel’s constant need for reassurance and her attempts to  control whom her parents invited to their home were a source  of significant conflict. In the past, Rachel had remarked that  “maybe the world would have been better without me,” and  thus the parents were apprehensive about making any changes  that might worsen her mood. 

When providing psychoeducation, the therapist introduced  the parents to the concept of accommodation and explained  how it related to their situation. The therapist also stressed  that parental accommodation, although well-intentioned, can  actually create an obstacle to independence, whereas reduc 

ing accommodation can help parents launch their children into  adulthood. The therapist helped the parents to identify several  ways in which they accommodated Rachel’s behavior. Some eas ily identifiable accommodations included the actual funds and  lodging that supported Rachel’s overall avoidance of indepen dent life. More subtle accommodations included the frequent  reassurance parents provided and their acquiescence to Rachel’s  control of various aspects of home life. As part of SPACE-FTL,  the therapist suggested that the parents’ accommodation should  be reduced. For example, Rachel’s free access to her greatest  means of avoidance (i.e., online gaming) should be limited. The  mother was taken aback at this suggestion, saying, “How can I  disconnect her from the world like that?! She is 23, she should  have access to the internet!” The therapist helped parents to see  that it is natural for them to want to provide for their daughter  and be moved by her anxiety, but that their choices also lowered  the likelihood of Rachel coping more independently with her  challenges.  

Increasing parental support 

Another key component of SPACE-FTL focuses on increasing  parents’ supportive attitudes and responses toward the YA.  Support is defined in SPACE-FTL (as in the original SPACE) as  the integration of acceptance by parents of the child’s genuine  difficultly and distress, along with confidence by the parents in  the child’s ability to tolerate and cope with distress. If parents  reduce accommodation in a nonsupportive atmosphere, it may  prove counterproductive and leave the child feeling rejected or 

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criticized. Promoting a supportive parental style often requires  training away from two other styles that each differ from, and  contradict, the notion of support: protection and demanding  (Lebowitz & Majdick, 2020; Lebowitz et al., 2014; Lebowitz  & Shimshoni, 2018; Shimshoni et al., 2020). 

Protection. Protection can refer both to protection by parents  from the actual challenges and obstacles faced by the YA, and  to protection from the distress and discomfort caused by those  challenges or by the YA’s symptoms, such as anxiety. In the first  instance, protection signals to the YA that the obstacles they  face are indeed insurmountable and reduces the parents’ expec 

tation for the YA’s coping and function. For example, parents  may downplay the YA’s ability to face the job market, believ ing that their adult child cannot cope with others in the work place, deal with employers’ authority, or handle even simple  tasks. Likewise, parents who view working an entry-level job  in a supermarket as a “humiliating job that reduces the child’s  motivation” may inadvertently reinforce maladaptive beliefs in  the YA and promote greater avoidance. Similarly, parents are  frequently concerned about their child’s ability to lead an inde pendent life by maintaining an apartment, paying rent, and in  general taking care of themselves. As one mother half-jokingly  described her YA, “he can’t handle pouring milk on cereal.”  In the second instance, that of protection from distress, the  parents may view their child as so sensitive or vulnerable that  placing any functional expectations seems unreasonable, thus  promoting a self-image of disability and consequent avoidance  in the YA.  

In SPACE-FTL, parents are trained in developing and show ing confidence in their child’s ability as one element of the sup portive approach. In some cases, the parents’ lack of confidence  about simple tasks relates to their concern about the YA’s abil ity to ultimately handle larger and more distant goals. Breaking  down the goal into a series of discrete and more manageable  steps can increase the parents’ ability to communicate confi dence about the current small step. For example, one mother  worked on a plan that included her 28-year-old sending online  job applications. The mother recoiled: “He can’t work! What  will he do, be a dishwasher? He’s not good with people!’ The 

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therapist replied: “Maybe he can’t work with people, or perhaps  he actually can, but for now you and your son need to practice.  Do you think sending applications—without going to work—is  within your son’s reach?” Other parents are not confident that  the YA can succeed because they lack work experience, had a  hard time in high school, or were unsuccessful in past attempts.  For example, a YA who has dropped out of college will often  shake their parents’ confidence in their abilities and potential.  These parents’ lack of confidence is understandable. From the  parents’ perspective, the breakdown in the YA function (i.e.,  dropping out) was not expected and they fear it may recur.  Understanding the causes that have contributed to previous cri ses helps to restore confidence in the YA’s overall ability and to  promote a more supportive style in the parents. 

Demanding. Demanding occurs when parents communicate  to the YA that they either do not believe there are genuine prob lems interfering with the child’s function, or that they expect the  YA to immediately be able to act as though those problems do  not exist. In some cases, parents rigidly cling to a view of the  YA as they were in the past, before the onset of the current dif ficulties. The outcome is that parents may set overly high and  unrealistic expectations and are frustrated when the YA fails to  meet these expectations. Demanding parents may sound unem pathetic when they signal to the adult child what is expected  of them. For example, parents may pass along want ads for  high-caliber jobs they believe the child could theoretically hold,  or be dismissive of smaller steps the YA is actually taking. For  example, one father said to the therapist, “All he does is drive  for Grubhub, it’s not even Uber!” 

In SPACE-FTL, parents are trained in developing and show ing acceptance of the YA’s condition, as another element in the  supportive message. This process is often challenging, and par ents may struggle to accept the change in their child or the genu ine difficulties they face. When children functioned well in the  past, for example in school, a breakdown in function may be  interpreted as the result of low motivation rather than as the  manifestation of a mental health condition. Rather than accept  that their child is currently struggling with a real-life challenge,  parents may reminisce about the YA’s pre-FTL condition, such 

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as the YA’s past work experiences, romantic relationships, or  sports activities, and may struggle to adapt to changing expec tations. The therapist can acknowledge and empathize with the  parents’ feelings, while explaining that a supportive approach,  including acceptance, is more likely to help the child in over coming the challenge and restoring function than is denying the  

problems or expecting the child to make them disappear. Another difficulty in promoting parental acceptance can arise  when parents continue to view their YA more as a young child  than as an adult. Since the transition to adulthood has not gone  smoothly, parents may continue to treat the YA as a young child  who must be directed to the “right” decisions. Such attempts  to control the YA are usually not helpful and can exacerbate  the dependency trap. They can also ultimately contribute to fur ther accommodation and can provide the child with a narrative  whereby their own lack of function is explained by parents who  are “too controlling.” The therapist can help parents acknowl edge the YA’s transition to adulthood and help develop a more  appropriate communication style. Furthermore, the therapist  can help parents see themselves as equal to their children in  rights, and less beholden to providing “child care.” 

Case vignette 3: Increasing parental support 

Jerry, age 27, completed college and spent his time in his par ents’ house after he had lived for several years—with the par ents’ financial backing—in other cities. Jerry was spending his  days playing online games, reading news sites, and searching for  ways to get rich with minimal effort. The home atmosphere was  very tense, with constant fighting between Jerry and his parents.  The parents could not understand how a brilliant young man  with a college degree and financial backing could “fail so miser ably.” The mother kept sending Jerry want ads while the father  would knock on Jerry’s door in the mornings, yelling at him to  get up. Jerry was miserable, telling his parents that “I can’t do it,  and anyway, working is for chumps.” To help the parents show  more acceptance of their son, while still remaining determined  to improve his functioning, the therapist highlighted Jerry’s suf fering instead of his professional failure. The therapist told the  parents: “Your son is unwell right now; he is different from the 

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person you put through college. Asking him to function at the  same level right away is like asking a man with a broken leg to  run a marathon. Accepting that he is struggling doesn’t mean  giving up on him, and the work we’ll do together is more likely  to help than showing him yet another classified ad.” 

As the parents’ acceptance increased, the number of times  they demanded that Jerry get a job decreased. Yet, other criti cism continued. The mother complained that Jerry’s room was  messy and that she had to keep cleaning it. The father felt that  Jerry should have a more spiritual life and should accompany  him to church on weekends. The therapist perceived that these  parents were struggling to adjust to viewing Jerry as an adult  and addressed this by saying: “Jerry will always be your child,  but he does not have to be your young child, just as you are not  your parents’ young children. Your parents do not check in with  you and come and clean your room. I think Jerry is more likely  to behave like an adult when his parents start to see and treat  him like one.” 

Supportive statements. A supportive statement should con tain the two components of support, communicating both  acceptance of the child’s hardship and confidence in the child’s  ability to cope with challenges. Parents in SPACE-FTL practice  making such supportive statements frequently to the YA, setting  the stage for their reduced accommodation and the potential  difficulty this will cause for the child (see Table 2). Commu nicating supportively does not come naturally for all parents,  and the difficulty can be compounded by challenging responses  on the part of the YA. For example, some parents will express  that “I do not talk this way” or “it is hard being accepting of  someone who does nothing all day.” And parents may report  that their YA reacted negatively to their attempts at support.  As one YA put it to his parents: “I do not need your hippie  BS!” In SPACE-FTL the therapist will encourage the parents to  maintain a focus on their own behavior and to focus less on the  short-term response of the YA. Parents can also be helped to tol erate the YA’s responses by reminding them that anxiety is often  manifested through aggression or anger and that the YA may  find it easier to say something aggressive than to acknowledge  their own challenge or distress.

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Table 2. Supportive statements 

Old Statements New Statements 

After four days, Bart’s parents have changed the house wi-fi password as part of reducing  their accommodation. Bart then complains to his parents: “This isn’t fair! How come you  guys get free access?” 

Mother: “Fair?! It is our internet! The nerve  you have. You should work hard, as I  know you can, and start paying for your  own.” 

Mother: “I know it is not easy to have less  control of your life than you would like to,  but I know you can handle getting a job  and becoming more independent.” 

William has been job searching for several days, but he has had no luck. William tells his dad:  “I do not want to do this anymore, I have tried before and it did not work . . . ” 

Father: “Son I know it is hard to find a job, I  was your age once—but there is no other  way of becoming independent. So if you  want to have control over your life, you’ll  just have to do it.” 

Father: “Son I know it is hard to find a job, I  was your age once—but there is no other  way of becoming independent. I believe in  you, I really do think that you can find a job  and persist in it.” 

Refusing to let her parents remove all Japanese comic books from her room, Rachel says to  her parents: “These are my books! They are mine! I need them!” 

Mother: “These are just books, and they are  ^{ruining your life! I know you can do with} out them, you are a strong woman and you  can do it!” 

De-escalation 

Mother: “I know this is hard for you, these  are not just books to you, they help you feel  better about yourself. I know you can do  without them, you are a strong woman and  you can do it!”

SPACE-FTL is informed by principles of nonviolent resistance  (Dulberger & Omer, 2021; Omer & Lebowitz, 2016; Wein blatt & Omer, 2008), a philosophy and therapeutic approach  that emphasizes self-change rather than attempts to control the  other, as a powerful means of promoting change while avoiding  unhelpful conflict and escalation. Throughout treatment, par ents are coached to act in a unilateral and determinedly non violent fashion. This applies both to the day-to-day interactions  with the YA (e.g., the YA’s refusal to help the parents with daily  house chores) and to more heated points of friction between  parent and child. Thus, although certain parental steps, such  as the reduction in services and accommodations they provide,  have the potential to trigger resistance or anger on the part of  the YA, parents are coached not to escalate these interactions  and to refrain from attempts to directly force change on the  child. Rather than attempting to “win” through arguments or  

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force, parents are encouraged to adopt a conciliatory stance, in  which they are taking necessary steps to help their child, and to  project that they see the process as one they are doing for, and  with, the child. 

Case vignette 4: De-escalation 

Colin, age 24, was a young woman who left her parents’ home  for 6 months after high school but then returned and refused  to leave. Her parents were at a loss. Colin was aggressive and  offensive whenever her parents suggested that she attempt any 

thing, lashing out at both of them. At times, the parents tried to  argue with her (often through her shut door) or, as the father  would put it, “We need to fight her in her language of screams.”  Yet, predictably, the constant fighting did not help, and Colin  remained almost entirely secluded in her room. She spent her  waking hours online and painting, emerging only to eat, and  for short shopping trips with her mother (primarily for art sup 

plies, which the parents paid for). The therapist worked with  the parents on not lashing back at their daughter. This proved  useful after they began to reduce their accommodation of pro viding constant internet service. The father said: “Resisting and  not arguing is hard; for example, one day she came storming  out of her room, shouting entitled accusations, and demanding  I reconnect the internet. I held my ground and was able to say a  

supportive statement instead of shouting back.”  On one occasion, Colin stormed out of her room, snatch ing her mom’s phone and claiming that she had the same right  to be updated on world events as her parents did. Enraged by  the “theft,” the mother raced after her daughter, threatening to  take the door off its hinges. The therapist continued to work  on explaining the advantages of a nonviolent response to such  disruptive behavior and role-playing such responses in the ses sions. After a week, Colin demonstratively pulled the plug of  the family’s internet router while her mother was on a work  meeting. This time the mother asked Colin to stop, and when  Colin said she would not, the mother replied: “Colin, I know  this is hard on you, but I think you will be able to cope and  move out someday. In the meantime, I am planning to help you.  If that means that I’ll need to work from a coffee shop until we 

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move the router to a locked room that you have no access to,  then that’s what I’ll have to do.” As the mother was putting her  laptop in her bag and getting ready to go, Colin said, “You don’t  have to leave the house; I was just making a point. I won’t touch  the stupid router again.” 

Engaging supporters 

Supporters in SPACE-FTL are relatives, friends, professionals,  and any others who can assist the parents in the treatment pro cess. Supporters play important roles in SPACE-FTL because  parents may encounter many difficulties related to their interac tions with the YA. For example, when YA view their parents’  treatment-related steps as hostile, punitive, or inappropriate,  supporters can help to reinforce the parents’ supportive message  and actions. Supporters can also bolster the YA’s self-efficacy by  echoing the parents’ message of confidence in their ability to  change their present situation. For the YA, hearing from people  outside the nuclear family that the current situation is unten able can help to pierce a façade of wellness that some YA will  maintain despite clear lack of function, and it can prevent the  self-imposed isolation of YA who are attempting to withdraw  from the outside world. Another role of supporters is helping to  reduce escalation or aggression. The mere presence of an exter nal supporter, in person or even by phone or online, is often  enough to inhibit serious aggressive responses to parental steps.  

Case vignette 5: Engaging supporters 

Dana was a 28-year-old woman living with her parents who  spent most of her time secluded in her room. Her parents had  always been extra careful about respecting her privacy. Partially  due to Dana’s temper, both parents tried not to provoke her  anger, cross her path when she was irritable, or suggest any steps  toward independence. Even saying anything kind to Dana was  often received with scorn, as were words or gestures of affec 

tion. The biggest taboo was for either parent to actually enter  Dana’s room. Only Dana’s younger brother Roy refused to  abide by these rules. When Roy came home to visit, he would  drop his bags, rush up the stairs, down the hall, and straight into 

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Dana’s room where he would proceed to jump up and down on  her bed. Roy would then pull out all her drawers, move things  around, and proceed to chase a giggling Dana throughout the  house until he would corner her and give her a huge hug. The  therapist asked the parents: “How do you think Roy is getting  away with murder?” Dana’s mother replied, “Well, that is easy,  he just doesn’t play along.” 

A comparison of SPACE-FTL and other programs  for parents of young adults 

The key components of SPACE-FTL are also present in vari ous forms in other PT programs for YA (see Table 3). Psycho education is delivered in some PT programs for YA to educate  parents about their child’s condition (e.g., dispelling miscon ceptions about the child’s condition; Paswan & Kumar, 2021;  Whitney et al., 2012). Other programs provide psychoeducation  about substance consumption and the challenges faced by YA in  the transition to adulthood (Cooper et al., 2020; Curtin et al.,  2013; Grossbard et al., 2010; Smeerdijk et al., 2015). Several  programs inform parents about specific services and resources  available for their child’s condition, such as social support,  vocational training, employment, and legal rights (Burke, 2016;  Yildiz & Cavkaytar, 2020). In Kubo and colleagues’ (2020)  program for YA with FTL, a psychiatrist provided parents with  information about mental health, including background on  therapeutic approaches, first aid for mental health, and support ing resources for people with FTL. Overall, the psychoeduca tion provided as part of SPACE-FTL resembles that of other  programs, although the scarcity of available resources for FTL  makes providing information about these resources less central.  

The SPACE-FTL component of reducing parental accommo dation has parallels in other PT programs for YA. For example,  Miller and colleagues (1999) guided parents on interfering and  competing with their adult child’s drinking. Whitney and col leagues (2012) conducted a PT for YA with anorexia nervosa  to decrease the number of interactions in which the parent is  overprotecting the adult child. Golan and colleagues’ (2018)  PT program includes a specific component of reducing parental  accommodation by training parents in providing less assistance 

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_{Table 3. Parent training component}s 

₁3 ₁2 ₁1 ₁0 9 8 7 6 5 4 3 ₂C ₂B ₂A 1 

X 

X X X X 

X X X 

X _{Psychoeducatio}n 

X X X X 

X X X 

_{Teaching/Instructing} 

X 

X X 

X _{Increasing parental suppor}t 

X 

X X 

X X 

_De-escalation 

X 

X 

X _{Reducing accommodatio}n 

X 

X X 

_{Promoting YA therap}y 

X 

X X 

_{Behavior modificatio}n 

X 

X _Acceptance 

X 

X _{Emotional suppor}t 

X 

X _Supporters 

_{Note. (1) Whitney et al., 2012. (2A) Miller et al. (1999), Al-Anon therapy. (2B) Miller et al. (1999), CRAFT training. (2C) Miller et al. (1999), Johnson Institute interven tion. (3) Grossbard et al., 2010. (4) Smeerdijk et al., 2015. (5) Curtin et al. (2013). (6) Golan, Shilo, & Omer, 2018. (7) Yildiz & Cavkaytar, 2020. (8) Burke, 2016.}  

_{(9) Paswan & Kumar, 2021. (10) Cooper et al., 2020. (11) Myers et al., 2018. (12) DiPipi-Hoy & Jitendra, 2004. (13) Kubo et al., 2020. Study collection method is given}  

_{at https://archive.org/details/osf-registrations-bnafu-v}1

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to their child when the YA can function independently. SPACE FTL stands out, however, for the central emphasis it places on  the reduction of parental accommodation. 

Several programs include elements that are comparable to  the SPACE-FTL component of increasing parental support. For  example, some programs train parents to more effectively com municate with their child (Grossbard et al., 2010; Miller et al.,  1999). Other programs work to enhance parental acceptance  of the YA’s condition. For example, parents of YA with alcohol  addiction were coached to accept that they do not have power  over the YA’s drinking behavior (e.g., Miller et al., 1999). Parents  of YA with schizophrenia who also used cannabis were trained  to distinguish between behaviors that patients cannot change  and behaviors that they will not change (Smeerdijk et al., 2015).  The focus on increasing acceptance may be absent from certain  programs because many pathologies manifest early in life (e.g.,  autism), and when parents attend the PT programs for YA, they  have already accepted their child’s condition, making working  on acceptance less necessary.  

The confidence element that is prominent in SPACE-FTL is  not as prominent in other programs. In SPACE-FTL, the parents  provide confidence to affirm their intention not to accommodate  and instill in their adult child a view of themselves as capable  and competent individuals. In other areas of psychopathology,  increasing parental confidence (and the expressions thereof)  may be less suitable, such as when the adult child’s capacity for  change is low. 

De-escalation training was provided in programs targeting  parents’ reactions to YA’s aggressive and dangerous behaviors.  Two programs had a specific component promoting nonhostile  and anti-escalation responses by parents (Golan et  al., 2018;  Smeerdijk et al., 2015). Miller and colleagues (1999) used Com 

munity Reinforcement and Family Training (CRAFT) to instruct  parents of YA who abuse alcohol on how to handle dangerous  situations concerning the YA’s alcohol use. In Whitney and col leagues’ (2012) PT for YA with anorexia nervosa, parents were  coached to decrease the number of critical and hostile interac tions between parent and child.  

The use of supporters is also present in other PT programs  for YA. For example, in Golan and colleagues’ (2018) approach, 

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supporters gave encouragement and legitimacy to the parents’  actions, and provided actual help when the YA needed assis tance. Although Whitney et al.’s (2012) program for YA with  anorexia nervosa does not explicitly mention the use of sup porters, the family-to-patient participation ratio was 2.5:1 and  

included additional family members, such as siblings.  We identified certain components that were used in PT pro grams for YA that are not central to SPACE-FTL. First, two pro grams provided parents with direct emotional support (Miller  & Rollnick, 2012; Whitney et al., 2012). SPACE-FTL is simi lar to other programs in which parents need emotional support  for both the generally tense daily interactions with the YA and  the more intense interactions between the parent and the child.  Although in SPACE-FTL therapists support parents throughout  the treatment process, direct emotional support of parents is not  one of the key components of the program, which maintains its  focus on modifying the parent–child interactions. Nonetheless,  when parents need greater emotional support but are not receiv ing it through other treatment, a greater emphasis on emotional  support for parents may be beneficial. 

In several PT programs for YA, parents are actively coached  to encourage their adult child to attend therapy (Kubo et al.,  2020; Miller et al., 1999). In our experience, most parents do  not require encouragement to promote therapy for the YA,  making this component less necessary. Furthermore, no direct  YA-based therapies are well established for the treatment of  FTL (e.g., McConville, 2021). Nonetheless, in SPACE-FTL, par 

ents are encouraged to help provide for therapy if the YA shows  interest in participating in it, and the YA’s attending their own  treatment is viewed as a positive step toward independence.  

In several programs, parents learned how to teach their child  a specific skill (Cooper et al., 2020; Curtin et al., 2013; DiPipi Hoy & Jitendra, 2004; Grossbard et  al., 2010; Myers et  al.,  2018; Paswan & Kumar, 2021; Yildiz & Cavkaytar, 2020).  SPACE-FTL does not include a specific skill-teaching compo nent for parents to teach to the adult child. Rather, it emphasizes  confidence in the YA’s abilities and the fostering of these abili ties through promoting a series of gradual steps toward inde pendence. Nonetheless, parents in SPACE-FTL are encouraged  to assist their child in gaining skills (e.g., writing a CV) when 

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the YA is open to such assistance. For example, parents may be  encouraged to provide outside help through vocational consul tants and other resources.  

Three programs coached parents on modifying the YA’s  behavior with sanctions and reinforcements (i.e., behavioral  modifications; Curtin et al., 2013; Miller et al., 1999; Paswan &  Kumar, 2021). SPACE-FTL (like the original SPACE treatment)  focuses on modifications to the parents’ own behavior and aims  to bring about change in the adult child through actions that are  entirely under the parents’ control and discretion. The reduc 

tion in parental accommodation, which comes closest of all the  treatment components to behavior modification strategies, is  not conceptualized as a “punishment” for the child not behav ing in a given manner, but as a determined effort by the parents  not to be providing the means of maintaining dysfunction. Like wise, when parents do provide services or items, these are not  construed as a reward for a desirable behavior, but as a natu ral allocation of resources to a loved child in need. The critical  factor in providing or withholding such actions and services is  whether they are understood to be promoting or impeding prog ress toward more adaptive functioning. Thus, for example, pro viding access to the internet in the parents’ home can be viewed  as an impediment to the adult child’s success when it is contrib uting to disrupted sleep or excessive online gameplay, but it may  be adaptive and helpful when the internet is being used to seek  jobs or for entertainment as long as it is not facilitating avoid ance behaviors. SPACE-FTL emphasizes praise by the parents in  response to signs of progress or functional steps taken by the YA  

rather than the use of tangible rewards and prizes. The present review highlights both similarities and differences  between SPACE-FTL and other PT programs for YA. The differ ent PT components may reflect that different strategies are best  suited to different problems challenging adult children. Differ ent treatment components also require different resources (e.g.,  number of sessions; different kinds and levels of expertise from  the provider), and thus programs must prioritize which com ponents are used. For example, teaching parents how to assist  the YA in gaining technical skills may take fewer sessions than  training parents on reducing accommodation. Likewise, provid ing parents with psychoeducation requires different knowledge 

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from providing supported-escalation training. Finally, PT  approaches are informed by, and derived from, a variety of the oretical foundations relating to etiology, conceptualization, and  ultimately treatment of the challenges they aim to ameliorate.  There is room for considerably more research on adult PT pro 

grams, and particularly so for programs focused on FTL. Apart from SPACE-FTL, one other PT program is dedicated  to FTL. Kubo and colleagues (2020) have tested a PT for YA  with FTL based on similar previous programs (Nonaka, Sakai,  & Ono, 2013; Sakai et al., 2015; Sakai & Nonaka, 2013; note:  these cited works are not reviewed here because they are not  in English). The PT program is based on CRAFT (Smith &  Meyers, 2007), which was initially developed for substance  use disorders as a family intervention program. The program  was also based on a mental health educational/training pro gram for nonprofessionals in mental health (Kitchener & Jorm,  2002; Langlands, Jorm, Kelly, & Kitchener, 2008). Thus, the PT  program of Kubo and colleagues (2020) contains components  related to substance use disorders and mental health, and, like  SPACE-FTL, contains elements of psychoeducation, increasing  parental support, and de-escalation. However, unlike SPACE FTL, it does not focus on reducing parental accommodation,  and does emphasize promoting individual therapy for the YA.  A recently described program by Dulberger and Omer (2021) is  closely related to SPACE-FTL and shares most of its underlying  theoretical orientation and practical components. One differ ence is that Dulberger and Omer call for more extensive work  with supporters (e.g., specific guidance sessions for support ers moderated by the therapist). Another difference is that the  support provided by the parents is less structured than that  offered in SPACE-FTL. The suggested program also does not  pose restriction on the population of young adults that may be  suitable for PT.  

Discussion and summary 

Millions of individuals and their families struggle with FTL  (Chandler & Lozada, 2021; Fry et al., 2020), and at this time  few intervention protocols exist to address this problem. SPACE FTL is a modification of an efficacious PT approach developed 

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for childhood and adolescent anxiety and obsessive-compul sive disorder, adapted for use with parents of individuals with  FTL. An advantage of SPACE-FTL (and potentially of other  PT approaches) is the ability to intervene even when the YA is  not amenable to direct participation in treatment. Preliminary  indications support the promise of this approach to addressing  the challenge of FTL, and additional clinical trial research is  currently under way to better establish its efficacy and identify  any additional refinements or adaptations that may optimize its  delivery. 

In the present review, we have discussed the different com ponents of SPACE-FTL, couched in the framework of other  PT programs for YA. Overall, the comparison highlights five  key components of SPACE-FTL that are commonly used in one  form or another by other PT programs for YA. The compari son also reveals certain components that are largely absent from  SPACE-FTL. One such element is educating parents about addi tional resources that may be useful to them in contending with  the challenges of their YA. Although resources aimed specifi cally at the issue of FTL are sorely lacking, other services may  be available to assist individuals with FTL or their parents. For  example, vocational rehabilitation services have a lot of experi ence in engaging individuals who have been out of the work for  long periods. It is possible that SPACE-FTL could be enhanced  by more emphasis on encouraging parents to be active in seek ing such services, cooperating with their workers, and facilitat ing the process. 

By providing an overview of the SPACE-FTL treatment pro cess and components, this review might also inform or enrich  the designs of other programs. For example, by showcasing the  role of reducing parental accommodation as a treatment tar get, other programs may incorporate a similar emphasis in their  treatment models. One PT program for YA that does make use  of this component was provided to parents of YA with autism  spectrum disorder, with good results (Golan et al., 2018). Reduc ing parental accommodation may prove to be a useful interven tion target for additional problem areas. 

SPACE-FTL derived from a treatment designed to treat anx iety in youth. The adaptation of such a program to the FTL  population is natural given the high prevalence of anxiety 

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disorders among individuals with FTL (Power et al., 2015; Teo  et al., 2015) and the role of avoidance that is central to both  anxiety disorders and FTL. However, given high heterogeneity  among individuals with FTL and the variety of problems that  might contribute to unsuccessful transitioning to independent  and functional adulthood, additional research is required to bet 

ter understand the characteristics of individuals most likely to  respond to SPACE-FTL. It is plausible that other treatments,  with different components, skills, and strategies, would be bet ter suited to various subsets of the population. Another direc tion for future research would be to expand SPACE-FTL to  other types of adult–adult relations characterized by high lev els of dependence, such as certain marital dynamics and other  adult–child relationships.  

Despite the need for much additional research, including rig orous clinical trial testing, SPACE-FTL appears to be a prom ising potential solution to a very large problem with massive  public health impact and few current solutions. Our first chal lenge is to test the efficacy of SAPCE-FTL in improving the func tioning of young adults with FTL. To that end, we undertook  a randomized controlled trial (RCT) of SPACE-FTL (Berger &  Lebowitz, In preparation). The five key components of SPACE FTL discussed in this review were central to the implementa tion of SPACE-FTL in the RCT. Nonetheless, the study was  not designed to test the relative importance and impact of each  component separately; such a comparison will require addi tional research. 

While this review compares SPACE-FTL with other parent based programs, we also acknowledge the relevance of other  programs that focus on treatment for nonengaged patients with  other relevant mental health problems. For example, Pollard  (2007) described a treatment approach for individuals with OCD  who show ambivalence and resistance to treatment. Several of  the procedures described may also be useful in the treatment of  FTL (e.g., identifying treatment-interfering behavior and setting  readiness goals and objectives). Another example is treatment  programs for pathological demand avoidance (i.e., individuals  who have “an obsessional avoidance of the ordinary demands of  daily life” [Newson, Le Marechal, & David, 2003, p. 596]). Dun 

can, Healy, Fidler, and Christie (2011) have suggested parental 

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strategies and ways of developing emotional well-being and self awareness in that context. One more example can be found in  behavioral activation programs for individuals with debilitating  depression and avoidance, a condition relevant to FTL. Namely,  some behavioral activation practices involve procedures that are  carried by the individual’s parents and are also a form of reduc ing parental accommodation (e.g., a mother will stop doing her  adult child’s laundry and dishes, so the child will become more  

active by doing those things; Kanter et al., 2010).  Considering the conceptual framework of intervention devel opment laid out by Onken, Carroll, Shoham, Cuthbert, and  Riddle (2014), the development of SPACE-FTL intervention is  presently at Stage 1B (i.e., intervention refinement). Specifically,  our present challenges are refinement, feasibility, and pilot test ing. Additional important goals at this stage include provider  training, supervision, and maintenance of the fidelity of inter vention delivery. Proceeding with the intervention development  to Stage 2 (efficacy research; Onken et al., 2014) entails execut ing clinical trials designed to test the efficacy of the intervention  and examining the mechanisms of behavioral change. Currently,  we see the reduction of family accommodation as a central  mechanism for change in SPACE-FTL. Nonetheless, alterna tive or additional mechanisms may play important roles, such  as increasing the level of physical activity in the YA through  changes in parental behavior (Comas-Díaz, 1981; Lejuez,  Hopko, & Hopko, 2001; Martell, Addis, & Jacobson, 2001;  Teri, Logsdon, Uomoto, & McCurry, 1997). There is a docu mented link between physical activity and mood (Kanter et al.,  2010) that may be used in parent-based treatments to bring  about behavioral change. Finally, proceeding to Stage 3 of treat ment development would entail conducting effectiveness trials  in community settings. Such an endeavor will require further  development and rely heavily on findings from Stages 1 and 2. 

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Berger, U., & Lebowitz, E. R. (In preparation). Parental guidance for  parents of highly dependent adult children. ClinicalTrials.gov Identi fier: NCT04704583.  

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