DOI: https://doi.org/10.21203/rs.3.rs-1637071/v1
Background: The Parental Acceptance and Action Questionnaire (PAAQ) is a scale for evaluating a caregiver’s experiential avoidance. The Japanese version of the PAAQ (PAAQ-J) was developed by Mizusaki & Sato who highlighted the necessity to reexamine the number of the items of the PAAQ-J and its factor structure. Therefore, to appropriately evaluate the reliability and validity of PAAQ-J as formulated by Mizusaki & Sato, we conducted a survey targeting a larger-scale sample of infants and their parents.
Methods: This study examines the reliability and validity of the Japanese version of the Parental Acceptance and Action Questionnaire (PAAQ-J) among 2,000 mothers of infants aged 0–3, and evaluates their scores for the PAAQ-J, the Acceptance and Action Questionnaire-II (AAQ-II), and the Hospital Anxiety and Depression Scale (HADS).
Resluts: We conducted an exploratory factor analysis, further creating a PAAQ-J comprising 12 items and three factors (α = 0.80): Inaction-Behavior (Inaction-B), Inaction-Cognition (Inaction-C), and Unwillingness, with α of 0.84, 0.72 and 0.68, respectively. As in the original edition, the Confirmatory Factor Analysis results of the two-factor models show poor goodness of fit. The test re-test reliability examination results showed that the Interclass Correlation Coefficient (ICC) was 0.49, with 95% CI between 0.44 and 0.54. The correlation coefficient (r) of PAAQ-J was 0.57, 0.32 and 0.33 with AAQ-II, and depressive and anxiety symptoms in the HADS respectively.
Discussion: Thus, PAAQ-J’s validity to adequately evaluate an individual’s avoidance of experiences vis-à-vis childcare, as well as their psychological flexibility, was proven. Since the original version of the PAAQ was for 6-18-year-old children with anxiety symptoms, it is necessary to examine its reliability and validity not only for infants and toddlers but also for parents of older children and adolescents in the future.
Acceptance and Commitment Therapy (ACT) differs from traditional cognitive behavioral therapy (CBT) as it emphasises the function and background of psychological phenomena rather than the content and format of thoughts, emotions and sensations (1). ACT aims to further psychological flexibility by promoting openness and awareness, and enabling flexible conduction of actions and adoption of behaviors that are backed up by an individual’s values (2). Psychological flexibility is enhanced through the six core pathological processes: Mindfulness, Acceptance, Defusion, Self-as-context, Committed Action, and Values (3).
ACT would be useful for caregivers, who manage various difficulties by targeting experiential avoidance and cognitive fusion (4). Previous studies show that caregivers who rely on experiential avoidance tend to control or suppress psychological pain related to a child’s difficulties, without taking appropriate actions backed up by adequate actions and behaviors (4). Unlike conventional cognitive behavioral approaches, ACT specifically focuses on value. Adopting adequate actions and behaviors without avoiding unpleasant experiences enables the adoption of long-term behaviors (5).
A systematic review of ACT based on parental support concludes it as a promising intervention that helps parents manage the stress and difficulties associated with autism (6), pediatric diseases (7, 8), children’s chronic pain (9, 10), etc. (11). In this context, ACT-based parental support as well as assessment tools for parents are actively being developed (12, 13).
The Parental Acceptance and Action Questionnaire (PAAQ) is a scale for evaluating a caregiver’s experiential avoidance (14). It is a self-administered seven-point scale questionnaire comprising 15 items, developed based on the Acceptance and Action Questionnaire (AAQ; 14); which was developed to measure psychological flexibility. The Japanese version of the PAAQ (PAAQ-J) was developed by Mizusaki & Sato (15) who highlighted the necessity to reexamine the number of the items of the PAAQ-J and its factor structure. It is attributable to its small sample size (n = 47). The Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) recommends that the sample size should be more than seven times the number of items, ideally exceeding 100 (15), which is not subscribed by PAAQ-J as it has only 47 subjects.Therefore, to appropriately evaluate the reliability and validity of PAAQ-J as formulated by Mizusaki & Sato (15), we conducted a survey targeting a larger-scale sample of infants and their parents.
Participants
The data was collected in December 2020. Participants were recruited by Rakuten Research, Inc., an online marketing research company that possesses the contact details of approximately 2.3 million Japanese survey respondents. Randomly selected individuals from Japan,stratified by gender and age, were sent an e-mail containing a link to an online questionnaire.
The participants were 2,000 mothers of children aged 0 - 3 (500 mothers of 0-year-olds, 500 mothers of 1-year-olds, 500 mothers of 2-year-olds, and 500 mothers of 3-year-olds); the children’s mean age was 1.57 ± 0.74 years; the mothers’ mean age was 33.58 ± 4.7 years. The inclusion criterion included mothers whose children were aged 0 - 3. There were no exclusion criteria. Mothers who had multiple children in the targeted age group were asked to answer the questionnaire, considering only one of them. Out of these, 1,000 participants (223 one-year-olds, 234 two-year-olds, 291 three-year-olds, and 252 four-year-olds) underwent another survey fourteen months later to examine test-retest reliability.
Measures
Demographic information
We asked the participants to provide information on their age, existing infirmities (mental, physical, premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD)), employment status, and number of births. We also collected information regarding the number of children, the target child, age of the child, and status of the child birth order.
Japanese version of Parental Acceptance and Action Questionnaire (PAAQ-J)
The PAAQ is a 15-item self-reporting-style questionnaire and is evaluated on a 7-point scale (from 1 [Never True] to 7 [Always True]) (14). The PAAQ-J was developed and structured by Mizusaki and Sato (15). However, its reliability and validity were insufficiently examined owing to its small sample size (n = 47). The higher the PAAQ-J score, the higher the tendency to avoid experiences. The questionnaire comprises two subscales, “Inaction” and “Unwillingness.” “Inaction” indicates a caregiver’s inability to functionally control their reactions to a child’s emotions, and “Unwillingness” indicates a caregiver’s inhibition to witness a child’s negative emotional experiences. The α-coefficients for Inaction and Unwillingness in the original PAAQ were 0.64 and 0.65 respectively; the total α-coefficient was 0.65.
Acceptance and Action Questionnaire-II（AAQ-II）
The AAQ-II is a self-reporting-style questionnaire comprising seven items that evaluate the important aspects of an adult’s avoidance of experiences and psychological flexibility on a 7-point scale (from 1 [Never True] to 7 [Always True]). The higher the score, the greater an individual’s tendency to avoid experiences (6). The Japanese edition of AAQ-II, which has an α-coefficient of 0.88, representing high reliability and validity; was developed by Shima et. al (16).
Hospital Anxiety and Depression Scale (HADS)
The HADS is a 14-item scale that evaluates anxiety and depressive symptoms: it comprises seven items for anxiety and for depressive symptoms (17). The subjects are asked to answer questions about each symptom on a scale of 1 - 4. The higher the scores, the stronger the symptoms are. The Japanese edition of HADS was developed by Hatta et al. (18). Cronbach's α-coefficient was 0.80 for anxiety symptoms, and between 0.59 and 0.61 for depressive symptoms.
Method of analysis
This study examines the scale’s reliability and validity according to COSMIN’s framework (19, 20).
Firstly, to verify structural validity, we conducted Confirmatory Factor Analysis (CFA), and assessed whether a two-factor structure could be hypothesized for PAAQ-J, as in the original PAAQ (14). Whenever a two-factor structure was invalid, we used exploratory factor analysis, employing maximum likelihood promax rotation, to investigate a new factor structure. The final extracted factors were subjected to CFA to ascertain the degree of fit.
Further, to examine the reliability of PAAQ-J, Cronbach's α coefficients were calculated for each of the factors. We then calculated the intraclass correlation coefficient (ICC) for each factor to examine the test-retest reliability of the PAAQ-J.
We also conducted a correlation analysis with AAQ-II to ascertain the PAAQ-J’s criterion validity. We further conducted a correlation analysis between PAAQ-J and HADS-depression/HADS-anxiety to investigate construct validity. We used SPSS Statistics ver. 27 (IBM Corp., Armonk, NY) and SPSS AMOS ver. 27 (IBM Corp., Armonk, NY) for our statistical analysis.
This study developed a Japanese version of PAAQ (PAAQ-J) and examined its reliability and validity. The results showed that PAAQ-J comprised three factors and 12 items.
Structural Validity
The Original PAAQ had a two-factor structure, comprising Inaction and Unwillingness. However, similar factor analysis could not be confirmed with CFA. Although three items were deleted after exploratory factor analysis, of the three factors, Factors 1 and 2 comprised Inaction items, while Factor 3 comprised Unwillingness items. The structures of original PAAQ and the PAAQ-J are similar. As Inaction was divided into behavior and cognition, the tendency to avoid experiences among Japanese may differ in terms of behavioral aspects and cognitive aspects. Furthermore, CFA was conducted assuming "Inaction" as a higher-order factor of "Inaction-B" and "Inaction-C," and the goodness of fit was obtained. As an example of avoidance of experience in parenting, Coyin and Murrell (21) present the latter. "Trying not think about something when it "shows up" in your thoughts," and "Avoiding or escaping being with individuals around whom such experiences tend to happen (21).” In other words, avoidance of experience includes visible actions, and avoidance of thoughts and feelings in the mind.
Reliability
The internal consistency and retest reliability of PAAQ-J were acceptable. When compared with the alpha coefficient of the original PAAQ, although the alpha-coefficient of Unwillingness was slightly low (α = 0.68), they were roughly similar (PAAQ vs. PAAQ-J: 0.65 vs. 0.68). Regarding Inaction and total, sufficient internal consistency appeared to be confirmed because PAAQ-J had a higher internal consistency (total: 0.65 vs. 0.80, Inaction: 0.64 vs. 0.84 [Inaction-B], 0.72 [Inaction-C], 0.74 [Inaction]). Likewise, the retest reliability showed that the ICC was 0.49. However, as this reexamination was conducted 14 months later, determining if this is an appropriate figure is difficult. Accordingly, given that the original PAAQ study did not confirm the test-retest reliability, this finding is significant.
In a nutshell, one could conclude that the PAAQ-J scale allows for relatively stable measurements.
Criterion and Construct Validity
The study further noted a significant positive correlation between PAAQ-J and AAQ-II. Criterion validity was further demonstrated, as AAQ-II is a gold-standard scale for evaluating the avoidance of experiences and psychological flexibility. A significant correlation was also noted between PAAQ-J and HADS-depression/HADS-anxiety. Avoidance of experiences is considered to be related to depression and anxiety symptoms. ACT is considered effective in alleviating these symptoms (22). We therefore concluded that the construct validity of the PAAQ-J has been demonstrated.
Based on this observation, the PAAQ-J has a 12-item, two-factor structure (Inaction [Inaction-B, Inaction-C] and Unwillingness), and is considered to have sufficient reliability and validity.
Limitation
This study has some limitations. Firstly, the findings might not be representative of parents with infants and toddlers as the survey was conducted online. Online surveys offer the advantages of convenience for participation and the ability to target a variety of people, who are not concentrated in area. On the contrary, there are disadvantages such as the unclear composition and representativeness of the registered population and the unclear relationship between the planned and collected samples.
Moreover, the participants were limited to parents with infants and toddlers. Since the original version of the PAAQ was for 6-18-year-old children with anxiety symptoms, it is necessary to examine its reliability and validity not only for infants and toddlers but also for parents of older children and adolescents in the future.
Thirdly, it is necessary to examine the appropriateness of the retest reliability period.
The PAAQ-J can adequately evaluate an individual’s avoidance of experiences vis-à-vis childcare, as well as their psychological flexibility. Developing interventions that enhance psychological flexibility of parents who experience difficulties in raising their children, and examining changes in the actions/behaviors and overall mood of parents and their children are necessary in the future.
Acceptance and Commitment Therapy (ACT), Cognitive Behavioral Therapy (CBT), Parental Acceptance and Action Questionnaire (PAAQ), Acceptance and Action Questionnaire (AAQ), Consensus-based Standards for the selection of health Measurement Instruments (COSMIN), Premenstrual Syndrome (PMS), Premenstrual Dysphoric Disorder (PMDD), Hospital Anxiety and Depression Scale (HADS), Confirmatory Factor Analysis (CFA), Intraclass Correlation Coefficient (ICC)
Ethics approval and Consent to Participate
All procedures performed in the study were in accordance with the ethical standards of the National Committees of Medical and Health Research Ethics and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was approved by the Research Ethics Committee of the University of Tokyo Health Sciences (17-27H) and Rikkyo University (21-31). Individuals who had submitted informed consent on the Web screen were accepted as participants.
Consent for Publication
Not applicable
Availability of data and materials
The datasets generated and/or analysed during the current study are not publicly available due under license for the current study but are available from the corresponding author on reasonable request.
Author information
Affiliations
Department of Psychology, Rikkyo University
Junko Okajima
Department of Psychological Counseling, Tokyo Kasei University
Isa Okajima
Competing Interests
The authors declare that they have no competing interests.
Funding
This work was supported by a Grants-in-Aid for Scientific Research -KAKENHI- Early-Career Scientists (Grant Number 25309).
Authors' contributions
JO analyzed and interpreted the patient data and was a major contributor in writing the manuscript. IO provided ideas for analysis and interpretation the patient data and was a major contributor in writing the manuscript.
Acknowledgments
We are grateful to all the participating parents with infants and toddlers in Japan who have taken part in this web study.
Informed Consent
Informed consent was obtained from all of the participants included in the study.
Tables 1 to 3 are available in the Supplementary Files section