Assessment of Parental Experiential Avoidance

Child Psychiatry Hum Dev
DOI 10.1007/s10578-009-0135-z
ORIGINAL ARTICLE
Assessment of Parental Experiential Avoidance
in a Clinical Sample of Children with Anxiety Disorders
Daniel M. Cheron Æ Jill T. Ehrenreich Æ Donna B. Pincus
Ó Springer Science+Business Media, LLC 2009
Abstract This investigation seeks to establish the psychometric properties of an adapted
measure of experiential avoidance (EA) in the parenting context by assessing its relation to
other parenting constructs and psychosocial correlates of child anxiety in a clinical sample.
Participants were 154 children (90 female, 64 male) diagnosed with anxiety disorders and
their parents (148 mothers, 119 fathers). The newly developed Parental Acceptance and
Action Questionnaire (PAAQ) was administered to parents along with self-report measures
of adult experiential avoidance, parental psychopathology, affective expression, and
parental control behaviors. A subsample of participants, n = 35, were re-administered the
PAAQ to assess temporal stability. Factor analysis of the PAAQ yielded a two-factor
solution with factors labeled Inaction and Unwillingness. Temporal stability of the PAAQ
was found to be moderate, r = .68–.74. Internal consistency was fair across subscales of
the PAAQ, a = .64–.65. Correlational analysis of the PAAQ and parent-report measures
support the criterion validity of the PAAQ, suggesting that the PAAQ correlates with
parent-report measures of parental locus of control, affective expression, and controlling
parental behaviors as well as child psychopathology symptoms. Finally, the clinical
applicability of the PAAQ is indicated by the PAAQ’s ability to predict a significant
amount of variance in parent- and clinician-rated levels of child anxiety and related
psychopathology.
Keywords Child anxiety Parenting Experiential Avoidance Assessment Control PAAQ Acceptance Acceptance and action questionnaire AAQ
D. M. Cheron (&) D. B. Pincus
Boston University Center for Anxiety and Related Disorders,
648 Beacon Street, 6th Floor, Boston, MA 02215, USA
e-mail: [email protected]
J. T. Ehrenreich
University of Miami, Miami, USA
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Introduction
Research over the past 20 years has focused increasingly on the phenomenon of anxiety
disorders in children and adolescents [1]. Previous literature has demonstrated that anxiety
disorders run in families [2]. For example, Last and colleagues [3] found significantly
higher rates of anxiety disorders in first-degree relatives of children with anxiety disorders
but not second-degree relatives. Children of parents with an anxiety disorder are also at
greater risk for developing an anxiety disorders themselves [4–6]. However, the specific
link between parents and their offspring with anxiety disorders is unclear [7], and prior
research has demonstrated that anxiety development may also be influenced by both
genetic and environmental factors.
Wood and colleagues [8] put forth that environmental factors including demonstrable
childrearing behaviors, may be significantly related to the development of child anxiety
(see [9] for review). Putative family factors have been studied in the literature and have
varying degrees of empirical support, including some forms of parental verbal expression
[10], family environments characterized by low warmth [11–14] and high parental control
[15]. Of these, greater use of controlling behaviors (or lower psychological autonomy
granting) may be the most consistently observed parenting variable(s) in families of
children with anxiety disorders [12, 16–22] and these controlling behaviors are consistently
correlated with child anxiety [8].
Silverman, Cerny and Nelles [23] reported finding greater levels of controlling behavior
amongst parents of children with anxiety disorders who have anxiety difficulties themselves. More specifically, parents high in anxiety may exhibit initial withdrawal from
interactions with their anxious child until the expression of child negative affect, at which
point parents seem to exert excessive control in these interactions [24–27]. While not
necessarily pointing to a causal role, these reports of greater control behavior in high
anxious parents, taken in context with the aforementioned data noting increased child
anxiety in controlling environments, suggest the importance of parental control in the
etiology of child anxiety. Yet the literature to date rarely postulates factors influencing
heightened levels of parental control behavior and communication patterns associated with
child anxiety, beyond parental psychopathology alone.
The concept of experiential avoidance may serve as a useful construct in understanding
potential factors at play in a parent’s use or overuse of control strategies in the context of
childhood anxiety. Experiential avoidance (EA) is defined as the phenomenon that occurs
when someone is unwilling to remain in contact with certain experiences and takes steps to
alter the form or frequency of these experiences even when this avoidance causes
behavioral harm [28]. Several therapeutic approaches hold some aspect of experiential
avoidance as important (see [28]) and this construct has received increased empirical study
as clinicians attempt to determine the interaction between experiential avoidance and
clinical difficulties. Determining this interaction demands attention because of the pervasive unhealthy consequences of escaping and avoiding negative emotions, thoughts, or
other experiences across multiple clinical syndromes [28]. Examining experiential
avoidance at work in the exercise of control behaviors in this context is thought to be
clinically useful [28]. To this end, recent work stemming from the field of Acceptance and
Commitment Therapy [29] has provided the scientific community with the Acceptance and
Action Questionnaire (AAQ) as a primary measure of experiential avoidance in adulthood.
Preliminary investigations indicate that the AAQ accurately measures this construct and
also demonstrates fair to good levels of reliability [29].
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If experiential avoidance motivates or guides the selection of control behaviors, it is
possible that the influence of experiential avoidance also warrants investigation in the
context of child-rearing, given the aforementioned influence of parental control on anxiety
development. To date, little research has been conducted on the impact EA has in childrearing practices. Research so far has postulated that experiential avoidance functions
across contexts [28]. Thus, it seems likely that a parent’s own experiential avoidance will
carry across contexts, including the parenting context. Measuring EA in the specific
context of parenting seems to be justified given the tremendous influence parenting
behavior has on child anxiety development [10, 11, 13]. However, given the distinctly
private experience EA is thought to represent [28], measuring EA in a particular context
such as in childrearing behaviors is challenging and likely requires a measure aimed not
just at one’s own private experience, but rather towards that experience in relation to
another. There is also a general lack of adequate and reliable tools to measure emotional
experiences in the family, namely willingness to experience emotion and the ability to take
action in emotional contexts [30]. Similar criticisms have also been voiced regarding more
generalized measures available for the assessment of families of children with an anxiety
disorder [31, 32].
Research Aims
Further investigation of EA in the parenting context may be stymied by the unavailability
of an adequate measure of parenting-specific EA. Therefore, the first aim of this research
was to develop an appropriate measure of parental experiential avoidance, called the
Parental Acceptance and Action Questionnaire (PAAQ), and establish its psychometric
properties in a clinical sample of children with anxiety disorders. This research also sought
to investigate how this subsequent measure of parental experiential avoidance (PEA)
relates to child anxiety symptomatology and the family environment of children with an
anxiety disorder more broadly, as well as its relationship to parent psychopathology in this
sample. Based on the literature above noting the close relationship of child anxiety and
parental control behavior, and the role of EA in controlling behaviors, we define PEA as
the phenomenon that occurs when a parent is faced with a situation in which their child
experiences an emotionally arousing incident and the steps that parent takes to control the
form or frequency of the child’s experience, even when this control causes behavioral
harm. Given the role of interaction between parent and child in the theoretical explication
of the role EA plays in the parenting context, it is postulated that PEA represents both a
parent’s unwillingness to witness their child experience negative emotion as well as a
parent’s inability to effectively manage their own reactions to their child’s affect.
After the development of the PAAQ as a proposed measure of PEA, the second aim of
this research was to determine correlations with concurrent measures to support the construct validity of this new measure. We anticipated that a moderate correlation would exist
between the PAAQ and the AAQ, given that the AAQ provided source material for the
PAAQ. Furthermore, it was hypothesized that the scales derived from factor analysis of the
PAAQ would correlate with existent measures of the family environment including measures of parent psychopathology, generally controlling behavior, and affective expression.
The third aim of this research was to determine whether the PAAQ is a useful measure
of the degree to which PEA accounts for differences in child anxiety symptomatology
above and beyond a parent’s own experiential avoidance and psychopathology. Given the
differences noted in the literature review above between individual experiential avoidance
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and parental experiential avoidance, it was hypothesized that the PAAQ would contribute
uniquely to child anxiety symptomatology, when controlling for parent psychopathology
and general EA. Differences between maternal and paternal reports were also explored,
given the potential for gender differences in EA overall [29].
Method
Participants
Initial Sample
Participants were 154 children and their parents recruited from consecutive assessments at
a university-based clinic specializing in childhood anxiety and associated disorders. Within
this sample, 113 mothers/fathers pairs were administered assessment procedures along with
35 mother-only participants and six father-only participants. No differences regarding
demographic information were found to exist between parent dyads and mother-only or
father-only participants on relevant measures of demographic characteristics (see Table 1).
Of the children whose parents participated in the study, 64 (41.6%) were boys and 90
(58.4%) were girls. The children ranged in age from 6 to 18.5 years, M = 11.86,
SD = 3.19. Participants were predominately non-Hispanic/White, n = 123, 79.9%. The
children presented with a wide variety of anxiety disorder diagnoses (Table 1); the mean
Clinical Severity Rating (CSR), a clinician-assigned rating of anxiety severity ranging
from zero to eight, was 5.54, SD = .94.
Reliability Sample
Participants in the reliability assessment were a subset of the full clinical sample above and
included 35 mothers and fathers. Within this sub-sample, 9 mother/father pairs were
assessed and 17 mother-only participants were assessed. No father-only participants were
assessed in this sample. Due to logistical issues, participants who received the repeated
administration of the PAAQ were necessarily limited to those on a waitlist to receive
treatment internally at the sponsoring clinic. This waitlist period ranged from 20 to
115 days, M = 64 days, SD = 20.12. However, there were no significant differences in
demographics between the subset of participants who completed the repeated administration of the PAAQ and the full set of participants who completed the first administration
of the PAAQ on age, gender, ethnicity, or clinical severity rating.
Measures
Measures Administered to both Child and Parents
Anxiety Disorders Interview Schedule for the DSM-IV, Child and Parent Versions
(ADIS-IV-C/P; [33])
The ADIS-IV-C/P is a semi-structured clinical interview for the diagnosis of childhood
anxiety and mood disorders as well as disruptive behavior disorders of childhood and
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Table 1 Demographic information of sample
N
%
113
73.4
Mother-only
35
22.7
Father-only
6
4.9
M
SD
45.3
6.1
$112,000
$71,600
11.87
3.19
5.54
.94
Parent demographics
Parent age
Mother/father dyads
Marital status
Single
10
6.6
128
84.8
Separated
4
2.6
Divorced
6
4.0
Unmarried domestic partners
1
.7
Other
2
1.3
Married
Estimated family income
Child demographics
Gender
Male
64
41.6
Female
90
58.4
Age
Ethnicity
African American
1
.6
Hispanic
2
1.3
123
79.9
27
17.5
1
.6
European American/Caucasian
Other
Unspecified
Child diagnosis
Generalized anxiety disorder
29
18.8
Separation anxiety disorder
26
16.9
Social phobia
24
15.6
Obsessive-compulsive disorder
19
12.3
Specific phobia
15
9.7
Anxiety disorder not otherwise specified
10
6.5
6
3.9
Panic disorder
Agoraphobia
2
1.3
Selective mutism
2
1.3
Post-Traumatic stress disorder
Co-Principal
Clinical severity rating
2
1.3
19
12.34
adolescence. Children and their parents were interviewed separately by a single interviewer. Resulting diagnostic information was based on composite information from both
interviews. During the assessment, they were asked about current symptoms as well as
severity of symptoms. A CSR was assigned to each anxiety and mood disorder diagnosis
by the clinician. CSRs range from zero (not at all interfering) to eight (very, very
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interfering), with a CSR of four and higher representing a clinical diagnosis. Reliability of
the ADIS-IV-C/P for the diagnosis of anxiety and mood disorders in children ages seven to
16 has been supported [34]. Preliminary inter-rater reliability analyses from 61 participants
at our clinic indicated good inter-rater agreement (r = .73) regarding diagnostic impression (i.e., what was assigned as principal diagnosis). Furthermore, corresponding scores
between the ADIS-IV-C/P and other measures of child psychopathology support the
concurrent validity of the measure [35].
Family Assessment Measure, Version III (FAM-III; [36, 37])
The FAM-III is a 50-item self-report measure designed to be completed by preadolescents,
adolescents, and adult family members. It measures seven basic constructs of family
functioning; communication, affective expression, role performance, task accomplishment,
involvement, control, and values and norms. Responses to items range on a four-point
Likert-type scale from strongly agree to strongly disagree. A total score is tallied by
summing individual items. For purposes of this investigation, the Control (FAM-C) and
Affective Expression (FAM-AE) subscales, each of which consists of 5 items, were
examined. High scores on the Control Subscale indicate patterns of influence that do not
allow family members to master the routines of ongoing family life. High scores on the
Affective Expression Subscale indicate patterns of inadequate communication involving
insufficient expression, inhibition of, or overly intense emotions in a given situation [37].
Internal consistency for the FAM-III subscales range from .65 to .87 [36]. Additionally,
temporal consistency correlations in a 12-day re-administration ranged from .48 to .77
across respondents.
Parent-Report Measures
Parental Acceptance and Action Questionnaire (PAAQ)
The PAAQ is a 15-item self-report questionnaire originally adapted for use in this study.
Parents are asked to rate the degree to which the following statements are true of them on a
seven-point Likert-type scale from 1 (Never True) to 7 (Always True). Its components and
psychometric properties are reported below and comprise a significant portion of this
manuscript. The PAAQ subscales measure both a parent’s unwillingness to witness their
child experience negative emotion (Unwillingness Subscale) as well as a parent’s inability
to effectively manage parental reactions to their child’s affect (Inaction Subscale). The
PAAQ Total scale, comprised of a combination of these two subscales, represents a parents
overall degree of parental experiential avoidance.
Child Behavior Checklist (CBCL; [38])
The CBCL is a 120-item parental report questionnaire designed to assess children’s
behavioral and emotional functioning. The CBCL is made up of an Internalizing Subscale
and an Externalizing Subscale to assess a range of behavioral difficulties. The Internalizing
Subscale is a composite of the Anxious/Depressed Subscale, Withdrawn/Depressed Subscale, and Somatic Complaints Subscale and was utilized in this research. The
Externalizing Subscale is a composite of the Rule-Breaking Behavior Subscale and
Aggressive Behavior Subscale. Additional subscales include the Social Problems Subscale,
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Thought Problems Subscale, Attention Problems Subscale, and Other Problems Subscale,
which are combined with the Internalizing and Externalizing Subscales to form the CBCL
Total Scale Score. Significant psychometric analyses have been performed on the CBCL
and have suggested that the reliability is acceptable. The internal consistency of the
measure ranges from 0.78 to 0.97 across scales. The test-retest reliability ranges from 0.95
to 1.00 across scales. Furthermore, the criterion validity was assessed and found to be
acceptable [39].
Depression Anxiety Stress Scales (DASS; [40])
The DASS is a 42-item parent questionnaire that measures an adult’s current level of
depression, anxiety, and stress over the past week. The DASS consists of three subscales.
The Depression Subscale assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest/involvement, anhedonia, and inertia. The Anxiety Subscale
assesses autonomic arousal, skeletal musculature effects, situational anxiety, and subjective experiences of anxious affect. The Stress Subscale assesses difficulty relaxing,
nervous arousal, easily upset/agitated, irritable/over reactive, and impatient. Higher scores
on all scales indicate higher levels of depression, anxiety, or stress. Psychometric testing
has yielded excellent internal consistency for the DASS in a clinical sample, a = .88–.96,
as well as adequate test-retest reliability, r = .71–.81 [41]. Comparisons of the DASS to
previously established measures show good convergent validity between the Anxiety scale
and measures of anxiety, r = .81–.84, and between the Depression Scale and measures of
depression, r = .74–.79 (see [42]). Divergent validity of all three scales provided support
for the validity of the DASS [41].
Acceptance and Action Questionnaire (AAQ; [29])
The AAQ is a 9-item self- report designed to assess the level of experiential avoidance that
adults have towards their own problem events. Given the recent release of this measure,
there are limited psychometric data available. Internal consistency of the AAQ was
reported at .70. Internal consistency in this sample is .73. The test-retest reliability of the
AAQ is around .64 over a 4-months time period. To assess the convergent validity of the
AAQ, it was compared with 11 measures of a similar nature, displaying the highest
correlations with measures of thought suppression, r = .44–.50 [29, 43] suggesting
acceptable validity. Further research on the AAQ items [43] yielded a two-factor solution
with good fit to the data. Specifically, the two factors consisted of Willingness (‘‘the
willingness to experience internal events’’) and Action (‘‘the ability to take action, even in
the face of unwanted internal events’’) [43].
Procedure
Measurement Construction
Initial construction of the PAAQ began with a 19-item composite version of the AAQ
[29, 43]. Although the AAQ is currently undergoing continuing modifications in an attempt
to determine the best number and configuration of questions (i.e., the AAQ-II is currently
under development and appears to have a stable factor structure with ten items), this
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19-item composite version provided an acceptable starting point for the PAAQ because it
includes all items from the 9-item version [29] for which statistical data are available as
well as items from the larger, inclusive 16-item version [29].
Next, appropriate changes to the wording of each question were made to direct the focus
of the PAAQ toward the child of the respondent and their individual parenting behaviors
towards that child. For example, the original item ‘‘If I could magically remove all of the
painful experiences I’ve had in my life, I would do so’’ was changed to ‘‘If I could
magically remove all of the painful experiences my child has had in his or her life, I would
do so.’’ The result was a 19-item measure that attempted to investigate the level of
experiential avoidance a caregiver had towards the experiences of the child in their care, or
parental experiential avoidance (PEA). Higher scores on the PAAQ indicate more PEA
towards childrearing situations.
Study Administration
Families who requested initial evaluations at the clinic provided informed consent to
participate in the two-part interview process. First, the interviewer met with the child while
the parent(s) left the room and completed the questionnaires. After the conclusion of the
child interview, the parent(s) were interviewed while the child completed his or her
questionnaires. If one of the child’s parents was not available for the assessment, every
effort was made to collect questionnaire data via standard mail. Following the completion
and review of the assessment, parent(s) and children were provided with feedback and a
clinical diagnosis summary. After providing feedback, those families that chose to receive
services at this clinic were placed on a waitlist until a clinician had availability in his or her
caseload. Once an opening was available, the family was scheduled for an initial session.
At this first session, re-administration of the PAAQ was conducted with a portion of the
participants as stated above.
Results
Because the PAAQ is hypothesized to measure a construct different than that of the
previously designed AAQ and because it was administered to only a subset of its intended
population (i.e., parents), an exploratory factor analysis was conducted to examine the
structure of the scale. Prior to beginning factor analysis, the PAAQ scores for mothers and
father were compared to determine if gender differences warranted separate factor analysis.
Results indicated that mothers’ and father’s reports on all PAAQ Scales did not differ
significantly. Additionally, PAAQ scores did not significantly differ by child gender or age
(see Table 2).
Factor Analysis
Using the entire sample of parents’ PAAQ responses (N = 267), maximum likelihood
extraction with Promax rotation was performed. The number of factors to include in the
analysis was determined by both requiring the eigenvalue of the factor to be greater than
one and through the use of the scree test [44]. Initially, a three-factor solution was indicated
that accounted for 36% of the variance (eigenvalues = 2.71, 2.51, and 1.64). However,
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Table 2 PAAQ total and subscale means, standard deviations, and correlations with child age
Parent gender
Child gender
PAAQ inaction
PAAQ unwillingness
PAAQ total
M
SD
t(265)
M
M
Mothers
25.2
6.2
-.69, N.s
Fathers
25.7
6.8
Male
25.8
6.8
Female
25.1
6.1
Correlation with child age
.82, N.s.
.11, N.s.
SD
t(265)
28.6
6.3
-.80, N.s.
29.1
5.3
28.1
5.9
29.4
6.0
-.10, N.s.
-1.7, N.s.
SD
t(265)
53.8
9.0
-1.0, N.s.
54.9
9.3
53.9
9.5
54.5
8.9
-.53, N.s.
.01, N.s.
N.s. Statistic not significant
because of weak factor loadings and numerous double-loaded items, a two-factor solution
was investigated. This two-factor solution accounted for 28% of the variance. Factor
loading for all 19 items is presented in Table 3.
The first factor, called PAAQ Inaction, somewhat resembled the Action factor for the
AAQ presented by Bond and Bunce [43], with five of the nine items loading on the factor
with no double-loadings (operationalized as a secondary loading of greater than .22). Two
additional items which had not been included on the measure developed by Bond and
Bunce also loaded onto the PAAQ Inaction factor (Items 17 and 19). Finally, two items
that had previously loaded onto the AAQ Willingness Factor determined by Bond and
Bunce now loaded onto the PAAQ Inaction Factor (Items 3 and 7), totaling nine items on
this factor. An inspection of these last two items suggests that the rewording of these
questions to apply to parents of children may have sufficiently changed the items enough to
better suggest a particular parent action and thus, warrant the change in factor. Overall,
factor loadings for the PAAQ Inaction factor after rotation ranged from .29 to .49.
The second factor, called PAAQ Unwillingness, closely resembled the Willingness
factor for the AAQ presented by Bond and Bunce [43]. Five of the seven items loaded onto
this factor with no double loadings. One additional item which had previously loaded onto
the AAQ Action factor now loaded onto the PAAQ Unwillingness factor (Item 14),
bringing the total number of items on the PAAQ Unwillingness factor to six. Factor
loadings ranged from .33 to .63. Again, the modified wording of this question provides a
basis for this change. Two of the remaining items had double loadings and were excluded
from the measure. Furthermore, two additional items had particularly low factor loadings
and were also eliminated from the measure, yielding the final 15-item measure.
Reliability and Validity of the PAAQ
Temporal Stability
Results from the re-administration of the PAAQ to participants in Sample 2, n = 35,
indicated moderate test-retest reliability for individual subscales on the PAAQ. The PAAQ
Inaction Subscale demonstrated lower, but adequate reliability, r = .68, and the PAAQ
Unwillingness Subscale displayed slightly higher reliability, r = .74. The Total Scale testretest correlation also yielded moderate reliability, r = .72. Furthermore, because testretest correlations would not detect systematic changes in scores over time, paired sample
t-tests were conducted as another test of temporal stability. The t-test for the PAAQ
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Table 3 Factor Loadings of PAAQ Items
Item
Factor
Inaction Unwillingness
1
I am able to take action about my child’s fears, worries, and feelings even if
I am uncertain what the right thing is to do.
.292
.063
2
When I feel depressed or anxious, I am unable to help my child manage
their fears, worries, or feelings.
.499
.024
3
I try to suppress thoughts and feelings about my child that I don’t like by
just not thinking about them.
.452
.002
6
In order for my child to do something important, I have to have all my
doubts about it worked out.
.270
.053
7
I’m not afraid of my child’s feelings.
.339
.178
10
Despite my doubts, I feel as though I can set a plan for managing my child’s
feelings.
.458
-.105
13
If I get frustrated with my child, then I can still help him or her.
.586
-.096
17
I often catch myself daydreaming about things I’ve done with my child and
what I would do differently next time.
.288
.200
19
When I compare myself to other parents, it seems that most of them are
handling their lives better than I do.
.467
.139
4
It’s OK for my child to feel depressed or anxious.
.087
.625
5
I rarely worry about getting my child’s anxieties, worries, and feelings
under control.
-.023
.376
8
I try hard to avoid having my child feel depressed or anxious.
-.162
.626
9
It is bad if my child feels anxious.
.172
.548
11
If I could magically remove all the painful experiences my child has had in
his or her life, I would do so.
.105
.437
14
Worries can get in the way of my child’s success.
.138
.335
18
When I evaluate something my child did negatively, I usually recognize
that this is just a reaction, no an objective fact.
.203
.064
15
My child should act according to his or her feelings at the time.
-.264
.135
16
If I promise to do something with my child, I’ll do it even if I later don’t
feel like it.
.302
-.254
12
I am able to control things that happen in my child’s life.
.222
-.297
Note: Factor loadings after Promax rotation of two factors extracted by maximum likelihood extraction
(Eigenvalues for the first ten factors were 2.71, 2.51, 1.64, 1.20, 1.12, 1.02, .98, .92, .91 and .79). Factor
loadings greater than .22 are in bold-face type
Inaction subscale was non-significant. However, the t-scores for the PAAQ Unwillingness
and Total Scales demonstrated a significant difference, p = .01 and .04, respectively,
suggesting some systematic change in scores over time. Inspection of mean difference
scores suggests that parents reported slightly fewer experiential avoidance symptoms at the
repeated administration (M = 54.1, SD = 7.8) than at the first administration (M = 56.3,
SD = 8.1).
Internal Consistency
The 15 remaining PAAQ items were subject to an analysis of internal consistency. Results
from this analysis yielded a range of alpha levels on the different subscales of the PAAQ.
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In the PAAQ Inaction Subscale, the data yielded a low internal consistency, a = .64. The
PAAQ Unwillingness Subscale evidenced a similar internal consistency value, a = .65.
Results from analysis of the 15-item PAAQ Total Scale also showed similar internal
consistency, a = .65.
Despite finding no differences between mother’s and father’s reports on the PAAQ,
correlations between the PAAQ and other measures of child and family functioning are
presented below for both parents. Given the differences in response patterns present in
these data as well as previous literature noting that mother-father correspondence on child
behavior is only moderate [45, 46], presenting the data for mothers and fathers separately is
warranted.
PAAQ Correlations with AAQ Scores
In an effort to provide convergent validity for the newly constructed PAAQ, correlations
with the original AAQ were investigated (Table 4). From these data, a significant positive
correlation was found between both Mothers’ PAAQ Total Scale scores and mothers’ AAQ
Total Scale scores. Mothers’ PAAQ Inaction and PAAQ Unwillingness Subscales also
demonstrated significant correlations with Mothers’ AAQ Total Scale scores. Significant
positive correlations also exist between Fathers’ PAAQ Total Scale scores and Fathers’
AAQ scores. Father’s PAAQ Inaction Subscale and PAAQ Unwillingness Subscale scores
also correlated with Fathers’ AAQ Total Scale scores.
PAAQ Correlations with DASS Score
To investigate the relation between PEA and parental psychopathology, correlations
between the DASS and PAAQ were compared (Table 4). In mothers, there was a significant
positive correlation between maternal scores on the PAAQ Total Scale and the DASS
Anxiety, Depression, Total Scales, but not the DASS Stress Scale, indicating that increase
PEA correlates with increased self-reported anxiety and depression amongst mothers. On
Mothers’ PAAQ Inaction Subscale, nearly identical correlations were found with the DASS
Anxiety, Stress, Depression, and Total Scale (Table 4). No significant correlations were
found between Mothers’ PAAQ Unwillingness Subscale scores and any DASS Scale scores.
After examining the responses of fathers, a similar pattern of correlations was found to
exist between PAAQ Total Scale scores and DASS Scores. Father’s PAAQ Total Scale
scores correlated with all DASS Scales. Furthermore, Fathers’ PAAQ Inaction Subscale
scores also correlated with all DASS Scales. These results indicate that higher fathers’ PEA
scores, particularly higher Inaction Subscale scores also correlate with higher self-reported
levels of psychopathology symptoms. In summary, these results indicated that higher
maternal and paternal levels of PEA, specifically avoidance of action in the context of
emotional experiences, correlate with higher levels of parent-reported psychopathology
symptoms.
PAAQ Correlations with FAM-III Scores
As a final investigation of the validity of the PAAQ, correlational analyses with parent-and
child-reported FAM-III scores were examined (Table 5). When investigating mothers’
reports, a significant correlation was found between Mothers’ PAAQ Inaction Subscale
scores and FAM-III Control Subscale scores, indicating that mothers who reported higher
123
123
* p \ .05; ** p \ .01
Fathers PAAQ
Mothers PAAQ
.55**
.40**
.64**
Total
.64**
Total
Inaction
.36**
Unwillingness
.52**
Inaction
Unwillingness
AAQ
.292**
M = 8.0
SD = 6.7
M = 1.7
SD = 2.6
.058
.283**
.116
.358**
M = 7.4
SD = 5.8
M = 1.8
SD = 2.9
.298**
.099
.005
.140
DASS
stress
.240**
.140
.211*
DASS
anxiety
Table 4 Correlations between PAAQ scores and other parent report measures
M = 2.6
SD = 3.3
.258**
.061
.308**
M = 2.2
SD = 3.5
.210*
.052
.255**
DASS
depression
M = 12.2
SD = 11.1
.319**
.080
.377**
M = 11.4
SD = 9.4
.214**
.066
.247**
DASS
total
M = 15.8
SD = 7.8
.231*
.158
.190*
M = 17.9
SD = 8.8
.156
.103
.121
CBCL
internalizing
M = 8.0
SD = 6.4
.185**
.156
.127
M = 8.6
SD = 6.4
.235**
.098
.241**
CBCL
externalizing
M = 39.6
SD = 21.0
.236*
.215*
.148
M = 44.3
SD = 21.4
.185*
.099
.167*
CBCL
total
Child Psychiatry Hum Dev
Inaction
.27*
M = 4.8
SD = 2.0
M = 4.9
SD = 1.4
.40**
.47**
Unwillingness
.32*
Total
M = 4.5
SD = 1.8
.41**
.03
Father FAM-III
control subscale
.31*
.17
-.03
Mother FAM-III
affective expression
subscale
Inaction
Total
Unwillingness
* p \ .05; ** p \ .01
Fathers PAAQ
Mothers PAAQ
Mother FAM-III
control subscale
M = 5.2
SD = 1.7
.35*
.21
.30*
Father FAM-III
affective expression
subscale
Table 5 Correlations between PAAQ scores and FAM-III scores and clinician-assigned clinical severity ratings
M = 5.2
SD = 2.2
.05
-.13
.16
-.23
-.19
-.12
Child FAM-III
control subscale
M = 5.1
SD = 2.4
.11
.05
.10
.03
.02
.02
Child FAM-III
affective expression
subscale
.204*
.262**
.066
.216**
.254**
.058
Principal
CSR
Child Psychiatry Hum Dev
123
Child Psychiatry Hum Dev
levels of experiential avoidance also report inhibiting individual independence in the
family. Mothers’ PAAQ Inaction Subscale scores also correlated positively with FAM-III
Affective Expression Subscale scores, such that mothers reporting more experiential
avoidance noted a family environment with more inadequate communication of emotions.
These findings were mirrored by fathers’ reports. Fathers’ PAAQ Inaction Subscale scores
correlated positively with FAM-III Control and Affective Expression Subscale scores.
Significant correlations were also found between Fathers’ PAAQ Unwillingness Subscale
scores and FAM-III Control Subscale Scores. Child reported FAM-III Control or Affective
Expression Subscale scores did not correlate significantly with any parent PAAQ Scale
scores.
Regression Analyses
Regression analyses were utilized to determine whether parental reports on the PAAQ
accounted for variability in measures of child anxiety and related psychopathology. Child
symptomatology and general child adjustment was measured by CBCL Total Scale scores
and CSR scores from the ADIS-IV-C/P. Since parent psychopathology, as measured by the
DASS, is likely to impact child symptomatology [47, 48] and parents’ own experiential
avoidance, as measured by AAQ score, demonstrated strong correlations with the PAAQ,
both of these variables were entered as a first step in the regression analysis, with the
PAAQ scores entered on the second step. Regression results are separated by parental
gender since differing patterns of relationship with child functioning were observed in the
correlational analyses.
Mothers’ CBCL Scales
A hierarchical regression analysis was performed with CBCL Total, Internalizing, and
Externalizing Scale scores as the dependent variable (Table 6). Using the DASS Total
Scale, AAQ Total Scale, and PAAQ Total Scale scores as the predictor variables and
CBCL Total Scale as the criterion variable, a significant model emerged. After step 2, with
PAAQ Total Scale score added to the prediction of CBCL Total Scale Score, change in R2
was significant. The addition of PAAQ Total Scale score into the model resulted in a
significant increase in the ability of this model to predict variance in CBCL Total Scale
Score. Based on the final model, the following coefficients had significant impact on CBCL
Total Scale score: DASS Total Scale score, Std. b = .25, p \ .05, and PAAQ Total Scale
score, Std. b = .28, p \ .05.
Regression models using the CBCL Internalizing Scale score as the criterion were also
significant. In this model, the significant impact on CBCL Internalizing Scale was significantly accounted for by PAAQ Total Scale scores, Std. b = .40, p \ .01. These
significant findings were not replicated by a model in which CBCL Externalizing Scale
was the criterion variable. Whereas DASS Total Scale continued to have significant impact
on CBCL Externalizing Scale score, Std. b = .23, p \ .05, PAAQ Total Scale was not,
Std. b = .15, p = .27.
Fathers’ CBCL Scales
Regression analyses performed on fathers’ responses were conducted in an identical
fashion as on mothers’ data. In the model using DASS Total Score, AAQ score, and PAAQ
123
123
** Sig. of change \ .01
* Sig. of change \ .05
Clinical severity rating
CBCL externalizing scale
CBCL internalizing scale
.02
.10
.04
2. PAAQ Inaction
2. PAAQ Unwillingness
.02
1. DASS & AAQ
.05
.11
2. PAAQ Unwillingness
1. DASS & AAQ
.11
1. DASS & AAQ
2. PAAQ Total
.12
2. PAAQ Inaction
.02
.11
1. DASS & AAQ
.12
.06
2. PAAQ Unwillingness
1. DASS & AAQ
.00
1. DASS & AAQ
2. PAAQ Total
.01
2. PAAQ Inaction
.11
.00
1. DASS & AAQ
.10
1. DASS & AAQ
2. PAAQ Unwillingness
2. PAAQ Total
.10
1. DASS & AAQ
.00
.06
2. PAAQ Inaction
1. DASS & AAQ
.06
.07
1. DASS & AAQ
.06
.11
1. DASS & AAQ
CBCL total scale
R2
2. PAAQ Total
Mothers’ predictor
variables (by step)
Criterion variable
.06
.00
.00
.00
.01
.00
.08
.09
.08
.09
.09
.09
.03
-.02
-.02
-.02
.07
-.02
.07
.04
.03
.04
.08
.04
Adjusted R2
.08
.02
.03
.00
.01
-
.01
.06
.01
.10
.04
.00
.05
D R2
2.90**
.82
.98
.82
1.31
.82
3.39
5.02**
3.61
5.02**
3.78
5.02**
1.82*
.136
.381
.136
2.97**
.136
2.97
2.76
1.89
2.76
3.33*
2.76
F
Table 6 Results of regression analyses on mothers’ and fathers’ self-report of child adjustment
2. PAAQ Unwillingness
1. DASS & AAQ
2. PAAQ Inaction
1. DASS & AAQ
2. PAAQ Total
1. DASS & AAQ
2. PAAQ Unwillingness
1. DASS & AAQ
2. PAAQ Inaction
1. DASS & AAQ
2. PAAQ Total
1. DASS & AAQ
2. PAAQ Unwillingness
1. DASS & AAQ
2. PAAQ Inaction
1. DASS & AAQ
2. PAAQ Total
1. DASS & AAQ
2. PAAQ Unwillingness
1. DASS & AAQ
2. PAAQ Inaction
1. DASS & AAQ
2. PAAQ Total
1. DASS & AAQ
Fathers’ predictor
variables (by step)
.07
.06
.07
.06
.08
.06
.17
.08
.13
.08
.19
.08
.12
.11
.14
.11
.15
.11
.18
.13
.17
.13
.23
.13
R2
.03
.03
.02
.03
.04
.03
.08
.05
.09
.05
.15
.05
.08
.08
.10
.08
.11
.08
.14
.10
.13
.10
.20
.10
Adjusted R2
.01
.01
.02
.04
.06
.11
.01
.03
.04
.05
.04
.10
D R2
1.73
2.19
1.55
2.19
1.90
2.19
2.84
2.79
3.33*
2.79
5.00**
2.79
2.83
3.98*
3.42
3.98*
3.73
3.98*
4.59
4.84*
4.39
4.84*
6.51**
4.84*
F
Child Psychiatry Hum Dev
Child Psychiatry Hum Dev
Total Score as predictors for Fathers’ CBCL Total Score, results proved significant. After
step 2, with PAAQ Total Scale score added to the prediction of CBCL Total Scale Score,
change in R2 was significant. Identical to results obtained with mothers’ reports, the
addition of PAAQ Total Scale score into the model resulted in a significant increase in the
ability of this model to predict variance in CBCL Total Scale Score. Based on the final
model, the following coefficients had significant impact on CBCL Total Scale score: DASS
Total Scale score, Std. b = .38, p \ .01, and PAAQ Total Scale score, Std. b = .44,
p \ .01.
Contrary to results obtained in the analyses of mothers’ responses, fathers’ PAAQ Total
Scale scores accounted for a significant amount of variability in CBCL Externalizing Scale
scores. In step two, with PAAQ Total Scale score added to the prediction of CBCL
Externalizing Scale Score, change in R2 was significant. In the model, the significant
impact on CBCL Externalizing Scale was significantly accounted for by DASS Total
Scale, Std. b = .30, p \ .05 and PAAQ Total Scale scores, Std. b = .45, p \ .01. Such
significant findings were not replicated by a model in which CBCL Internalizing Scale was
the criterion variable.
Clinician-Assigned Clinical Severity Rating (CSR) and Parents’ Reports
Hierarchical regressions were conducted with the clinician-assigned CSR as the criterion
variable (Table 6). In the following regressions, mothers’ DASS and AAQ Total Scale
scores were entered into the first step and the unique contribution of individual mothers’
PAAQ Scale scores was examined on step two. Initial analysis of mothers’ PAAQ Total
Scale scores yielded no significant findings. However, further investigation revealed that
the Maternal Unwillingness Subscale scores did account for a significant amount of variability in CSR. In step two, with the Maternal Unwillingness Scale score added to the
prediction of CSR, the model was significant. In the model, the significant impact on CSR
was significantly accounted for only by Mothers’ PAAQ Unwillingness Scale scores, Std.
b = .30, p \ .05. Fathers’ PAAQ scores did not significantly predict variance in CSR.
Discussion
To attain the first goal of this research, examination and modification of the AAQ was
conducted and the basis for the PAAQ was created. The parenting context, by its very
nature, involves interpersonal interaction [9]. EA as a construct was initially formulated as
a very private experience [28]. Thus, introducing an interpersonal interaction into this
private experience via the construct of PEA yielded factor loadings different than the
established literature [43]. Such differences in factor loadings seem to suggest that there is
something parents experience that is uniquely private, yet enacted through specific parentchild interactions in the parenting environment that also differentiate EA and PEA and that
warrants further investigation.
Given that Hayes and colleagues [28] noted the role of EA in controlling of unwanted
emotional experiences and Wood and colleagues [8] evidenced the role such behaviors may
have on the childrearing environment, the second aim of this project was to examine the
convergence of the PAAQ with similar measures that would support its construct validity.
As anticipated, when comparing scores on the PAAQ and the AAQ, parents who had higher
levels of EA themselves also responded in a manner moderately consistent with a parent
who expresses a significant amount of experiential avoidance in their parenting behavior.
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Child Psychiatry Hum Dev
Parents who reported elevated levels of PEA on the PAAQ also reported significantly
higher levels of depression and anxiety as measured by the DASS. However, a different
pattern of correlations were found between mothers and fathers, such that fathers’ stress
significantly correlated with PAAQ but mothers’ stress did not. Despite this discrepancy,
the research indicated that, in general, parents who feel as though they cannot address the
emotional experiences of their child through specific action-taking behaviors are also
parents who self-report greater problems with their own anxiety and mood difficulties.
When applied to the context of parenting, the PAAQ’s underlying relationship to parent
psychopathology becomes clear and seems buttressed by Woodruff-Borden and colleagues’ [24] notion that parents may engage avoidant parenting behaviors when
confronted with emotionally evocative parenting situations.
As expected, the correlations between the PAAQ and FAM-III subscales in this research
indicate that higher affective expression and greater levels of control are related to
heightened PEA as measured by the FAM-III-Affective Expression and Control subscales.
Such data are consistent with prior literature that states that control in the family environment is associated with a parental anxiety disorder [23] and increased child anxiety [15]
and that increased criticism and maladaptive communication impact family functioning in
ways similar to parental control and overprotectiveness [15, 49, 50]. However, when
children were the raters of parental control and affective expression, correlations with PEA
were not significant.
Overall, these findings seem to suggest that parents who respond in ways that indicate
they are avoidant of experiencing negative emotional arousal also respond in ways that
suggest they are avoidant of negative emotional experiences in their children’s lives. These
parents also report high levels of control in the parenting context and may have a desire to
avoid experiencing emotionally arousing events. The correlations between the PAAQ and
these established measures seem to support the construct of PEA and warrant further
analysis of the clinical applicability of such a measure.
For the third goal of this research, the ability of the PAAQ to account for variance in
child anxiety symptomatology was explored. As hypothesized, PEA as measured by the
PAAQ, accounts for a significant amount of variance in measures of anxiety in this clinical
sample of children, as rated by mothers and fathers. However, response patterns between
mothers and fathers appeared to differ somewhat. Fathers who report more difficulty taking
action when their child is experiencing negative emotion also report higher degrees of
dysregulation in their child. Conversely, mothers who report more unwillingness to witness
their child experience negative emotion report higher degrees of dysregulation in their
child. The differences observed between mothers and fathers may be the result of emotional or demographic factors, differences in sample sizes, pre-existing parental
psychopathology, or differences in rates of disclosure between parents [51]. However, such
differences may also be a result of the different impact emotionally evocative parenting
experiences have on mothers and fathers, a topic that may be of interest for future
investigation.
Because relying solely on self-report measures to determine the PAAQ’s clinical
applicability would be somewhat limiting (see [32]), an interview-based, clinician-rated
severity level of child psychopathology was also employed. Again, mothers’ levels of selfreported unwillingness to experience their child’s negative emotions as measured by the
PAAQ did indeed account for variance in clinician-rated severity levels of child symptomatology. Such a finding strengthens the notion that the PAAQ may have some utility in
determining the level of PEA in mothers that may be associated with increased child
symptomatology. However, this finding was not replicated in the reports of fathers. Such
123
Child Psychiatry Hum Dev
discrepancies have previously been noted to hinder research and accurate clinical assessment [45] and these discrepancies appear to be present in the PAAQ.
The results presented here suggest that the PAAQ may serve as a useful tool for
assessing EA in the parenting context. However, given the early stage of this area of
investigation, further research still needs to be conducted to address some of the limitations
of this study. Most notably, there is a great deal of shared source variance in the questionnaire measures as evidenced by high correlations, particularly between the AAQ and
PAAQ. Further revision of this measure is necessary to distinguish the precise constructs
that differentiate PEA from EA more generally and additional investigation of the factors
that may be involved in PEA is necessary. Additionally, due to logistical constraints, only a
clinically anxious sample of children was utilized in this study. Administration of this
measure to a normal control group is necessary in order to determine its utility in defining
PEA more thoroughly and assessing PEA more globally.
Although the preliminary reliability of the PAAQ is supported in this study, it will be
important for future work to focus on better assessing this reliability through more stringent control of re-administration conditions. As noted above, 35 parents were readministered the PAAQ when initiating treatment at the clinic where the previous
assessment had been administered. However, the range of time on the clinic waitlist for
these participants varied greatly (range = 20–115 days). Such variability in retest
administration amongst such a small sample may have distorted the actual reliability of the
PAAQ. Information regarding clinical and psycho educational services received during the
waitlist period was also not collected. Overall, interpretation of the reliability of the PAAQ
should be conducted with caution until future data can support assertions made about its
reliability. Broader assessment of the measure’s temporal stability would also greatly
benefit from data collected from participants who declined treatment to provide a better
representation of the population of anxious children and adolescents.
The internal consistency of the PAAQ is also in the low to moderate range, as noted in
the factor analytic section, and indicates that further revisions of the PAAQ items or factors
may be necessary before wider implementation can take place. Firstly, it is possible that
refining complexly worded items (e.g., Item 17) or eliminating items with low factor
loadings (e.g., Item 6) may help increase the internal consistency of the measure. Moreover, investigation of the construct of PEA via the PAAQ is limited in ways similar to the
limitations of the original AAQ [29], as both are very new measures. The AAQ has been
criticized for the complexity of its items, and items on the PAAQ are quite complex as
well. There are also numerous pitfalls associated with self-report measures [52], particularly when one self-report measure is used to validate another, as in this study. As the data
above indicate in this study, the strength of our finding becomes weaker when reports are
from independent observers (i.e., the child and the clinician), which is a significant
problem that must be further evaluated in order to clarify the utility of the PAAQ. Research
utilizing behavioral analogues of these questionnaires is needed. However, given the new
development of PEA as a construct, and the somewhat tedious existent behavioral measures of EA [53], it seems acceptable to begin with such a self-report measure to examine
EA in the parenting context.
Despite these limitations, the PAAQ serves as a step toward conceptualizing the role EA
may play in parenting. While the PAAQ demonstrated fair internal consistency, its stability
over time and correlation with measures hypothesized to be related to PEA provide support
for continued investigation into its usefulness. Furthermore, the PAAQ demonstrated the
ability to predict variance in child anxiety symptoms above other measures related to child
symptomatology (i.e., parent symptomatology). As a construct, PEA needs further
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Child Psychiatry Hum Dev
attention if its role in the family environment is to be better understood. However, based on
these early psychometric results, the PAAQ has sufficient support to continue investigating
hypotheses related to PEA as an influential parenting factor.
Summary
Literature has indicated that parental control behaviors may play a role in child anxiety
symptomatology. In this paper, we put forth that experiential avoidance in the parenting
context may relate to this exercise of controlling parenting behaviors. For this research, we
assessed 154 children ages 6.5–18.5 and their parents. The first aim of this research was to
develop an appropriate parent-reported measure of parental experiential avoidance. This
new measure, the Parental Acceptance and Action Questionnaire, demonstrated a twofactor structure consistent with existent literature [43], but subscales currently produced
low internal consistency. Furthermore, temporal stability was fair, indicating generally
reliable measurement over time. The second aim of this research was to investigate how
the PAAQ relates to child anxiety symptomatology and the family environment of children
with an anxiety disorder. It was hypothesized that moderate correlations would exist
between the PAAQ and measures of individual EA, parent psychopathology, measures of
control, and measures of affective expression. As expected, these hypotheses were supported based on data demonstrating significant correlations between the PAAQ and the
AAQ, DASS, and FAM-III. Finally, this research sought to explore the unique contribute
the PAAQ makes to child anxiety severity and overall psychological functioning. It was
hypothesized that the PAAQ would predict significant variance in child anxiety symptoms.
In accordance with this, holding parent psychopathology and individual EA constant, the
PAAQ accounted for a significant amount of variance in parent-rated and clinician-rated
child anxiety symptoms, supporting the hypothesis that the PAAQ accounts for a significant amount of variance in child anxiety symptomatology.
Appendix
See Tables 1, 2, 3, 4, 5, 6.
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