= Solution
Parents should have a negotiated, formulation-led role that helps an <adolescent> undertake effective treatment while supporting increasing autonomy. Three roles must be distinguished: facilitating access and practice, changing parental responses that maintain avoidance, and receiving treatment for the parent's own difficulties. A parent being present in more sessions is not a mechanism in itself. The relevant question is which parental action changes which maintaining process, for which <adolescent>, beyond the effects of <adolescent> treatment alone.
Initial assessment should obtain both the young person's and caregiver's perspectives on feared situations, avoidance, <Functional impairment>[impairment] and family responses. Separate discussion with the <adolescent> can reveal difficulties they would not disclose in a joint meeting. A shared formulation can then identify whether parents provide repeated reassurance, take over social interactions or organise routines around avoidance. <Family accommodation>[Accommodation] can bring immediate relief while reducing opportunities for the <adolescent> to learn that uncertainty and distress are manageable. Support can instead combine recognition of distress with confidence in the young person's capacity to approach an agreed activity. These descriptions concern potentially modifiable interactions, rather than assigning parental blame for the disorder's origin.
The role should fit developmental circumstances. A thirteen-year-old dependent on a caregiver for transport may need different practical support from a seventeen-year-old arranging appointments. Parents can help implement between-session practice, notice approach rather than merely the disappearance of distress, and support school coordination. The <adolescent> should help decide what information is shared and which sessions are joint, within clearly explained <confidentiality> and <safeguarding> arrangements. Parent involvement can undermine treatment if it becomes surveillance, coercion or another route for excessive reassurance. Fathers, other caregivers and relevant family relationships should be considered rather than assuming that the mother is always the appropriate participant.
Adolescent-specific evidence does not support mandatory additional parent sessions for everyone. <Polly Waite> and colleagues <Randomization>[randomised] sixty thirteen- to eighteen-year-olds in routine services to immediate or delayed <Internet CBT>, with an additional random allocation of parent sessions. The parent addition did not significantly improve <Diagnostic remission>[remission], either immediately or at follow-up, and the online programme itself did not clearly outperform waiting list on the primary <Diagnostic remission>[remission] endpoint. <Confidence intervals> were wide. This is evidence against assuming a reliable benefit from that particular addition, rather than proof that parental involvement is useless or that a modest targeted effect is impossible.<A randomized controlled trial of internet-delivered cognitive behaviour therapy for adolescent anxiety disorders in a routine clinical care setting with and without parent sessions by Polly Waite and others>[Child and Adolescent Mental Health 24, 242–250; randomised parent-session allocation, primary remission and follow-up]{ref}
Evidence from younger samples suggests hypotheses about selection. <Vanessa E. Cobham> and colleagues stratified families by <parental anxiety> before <Randomization>[randomising] sixty-seven seven- to fourteen-year-olds to <Cognitive behavioral therapy>[child CBT] with or without <parental anxiety> management. Their findings suggested greater benefit of the addition when a parent was anxious, but results varied across measures. The study motivates a moderator hypothesis; its small subgroups and younger participants limit a general rule for <adolescent> treatment.<The role of parental anxiety in the treatment of childhood anxiety by Vanessa E. Cobham and others>[Journal of Consulting and Clinical Psychology 66, 893–905; parental-anxiety strata and parent anxiety-management addition]{ref}
A larger test cautions against treating a plausible family risk factor as an established augmentation target. <Cathy Creswell> and colleagues studied 211 children whose mothers also had <anxiety disorders>. All received <Cognitive behavioral therapy>[child CBT]; additions targeted either maternal <anxiety> or mother–<child> interaction, with nonspecific contact balanced. The additions changed some maternal outcomes but did not clearly improve the primary <child> diagnostic outcome. Treating a parent's <anxiety> may be worthwhile for that parent without necessarily producing an incremental child-treatment effect. Family-risk association, target engagement and improvement in the <child>'s disorder are separate evidential steps.<Treatment of childhood anxiety disorder in the context of maternal anxiety disorder: a randomised controlled trial and economic analysis by Cathy Creswell and others>[Health Technology Assessment 19(38); 211-family trial, maternal CBT and mother–child interaction arms]{ref}
An alternative is parent-based treatment rather than parental augmentation of <child> therapy. <Eli R. Lebowitz> and colleagues <Randomization>[randomised] 124 seven- to fourteen-year-olds to <Cognitive behavioral therapy>[child CBT] or <SPACE treatment>, a parent intervention reducing <Family accommodation>[accommodation] without direct <child>–therapist sessions. <SPACE treatment> met prespecified <Noninferiority trial>[noninferiority] criteria for <anxiety> outcomes and reduced <Family accommodation>[accommodation]. This supports the possibility that changing caregiver responses can be an effective delivery route. It does not establish that replacing adolescent-focused therapy with parent work is appropriate across the older teenage years, or that the same approach is preferred by every young person.<Parent-Based Treatment as Efficacious as Cognitive-Behavioral Therapy for Childhood Anxiety: A Randomized Noninferiority Study of Supportive Parenting for Anxious Childhood Emotions by Eli R. Lebowitz and others>[Journal of the American Academy of Child and Adolescent Psychiatry 59, 362–372; SPACE treatment noninferiority trial, ages 7–14 and accommodation outcomes]{ref}
Together, these studies favour flexible involvement. A useful <clinical formulation> can identify practical support needs, <Family accommodation>[accommodation] that interferes with <learning>, and <parental anxiety> requiring its own assessment. However, personalised selection rules remain hypotheses unless prospectively tested. Neither a null augmentation trial nor a successful parent-only trial settles the optimal dose of parent contact alongside a given <adolescent> therapy. <Treatment fidelity> also matters: a nominally parent-inclusive programme may differ greatly in whether it rehearses supportive responses, changes <Family accommodation>[accommodation] or merely provides information.
A future study should therefore recruit <adolescents> with diagnosed <anxiety> across routine services and deliver the same adequate <adolescent> <CBT> in every arm. <Randomization>[Randomise] caregivers to a brief accommodation-focused module or a credible contact-matched education condition; an additional prespecified stratum could examine parents with their own <anxiety disorder>. Measure <Family accommodation>[accommodation] and <parental anxiety> before allocation, and <Statistical power>[power] the study for the specific treatment-by-baseline-characteristic interactions rather than searching retrospectively for successful subgroups. Include age, caregiver availability and <adolescent> preference in recruitment and reporting without treating chronological age as a complete measure of autonomy.
<Blinding>[Masked] diagnostic interviews, young-person-rated <Functional impairment>[impairment] and school or social functioning should be assessed after treatment and at six and twelve months. Parent reports should be retained as a separate perspective, not substituted for <adolescent> outcomes. Record what parents actually do through agreed observations or structured practice tasks, alongside session attendance and <treatment fidelity>. Measure changes in <Family accommodation>[accommodation] repeatedly before the proposed downstream improvement. Temporal <Statistical mediation>[mediation] would constrain a mechanism, although additional mediator–outcome assumptions would still be needed for a <causal mediation> claim.
The trial should also measure family burden, <Treatment acceptability>[acceptability] and any deterioration in relationships, and examine families unable to attend conventional sessions. An approach that improves completer outcomes while excluding caregivers with work or language barriers may reduce practical access. <Qualitative interviews> can explain why a module helps or fails, while the <Randomization>[randomised] contrast estimates its incremental effect. The 2022 evidence supports parents as potential partners, change agents and recipients of care, but supports a collaboratively chosen and testable role more strongly than indiscriminate intensification of parental attendance.
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