Psychological flexibility, the core treatment target in Acceptance and Commitment Therapy (ACT) [1
], is conceptualized as the ability for adaptive, values-oriented behavior in the presence of distressing experiences [2
]. Psychological flexibility has also been described as a “fundamental aspect of health”, with high relevance to distress, such as anxiety and depression, where there is typically a lack of flexibility [3
]. Current research further indicates that parental psychological flexibility may act as a possible moderator in the relationship between parent- and child-distress [4
], and also that psychological flexibility within the parenting role is associated with adaptive parenting behavior in non-clinical samples [4
There is emerging evidence for the utility of ACT in pediatric chronic pain [6
]. In the context of pediatric chronic pain, parental psychological flexibility is defined as the parent’s willingness to experience distress related to the child’s pain, in the service of long-term values and related behavioral goals for both parent and child [10
]. Research on parents of children with chronic pain has also shown a positive relationship between parental psychological flexibility and level of functioning in the child, and has pointed to the utility of targeting parental psychological flexibility in treatments with ACT for pediatric chronic pain, in order to potentially improve child treatment effects [10
]. There is also mounting evidence concerning the association between parental distress, such as anxiety, fear, catastrophizing, and depression, and functional disability in children with chronic pain [12
], even at subclinical levels of parental distress [15
]. For example, research shows that parental distress influences parent behavior toward more protecting and monitoring, which contributes to the child’s distress, fear, catastrophizing, and avoidance behaviors; factors with a direct impact on pain related functional disability in the child [16
Psychological flexibility appears to be a context specific construct, in terms of the area of study (e.g., pain, parenting, workplace, or other), and therefore needs to be assessed as such [4
]. This implies the need for reliable and valid instruments to assess parental psychological flexibility within the context of pediatric chronic pain. To date, only one such instrument has been specifically developed, the Parent Psychological Flexibility Questionnaire (PPFQ) [10
]. However, the PPFQ has not yet been validated in a Swedish sample. The first study by McCracken and Gauntlett-Gilbert included development of the PPFQ by generating a set of items constructed to reflect aspects related to psychological flexibility (e.g., acceptance, cognitive defusion, and values-based action), of which 24 of the original 31 items were retained for analysis. Results supported internal reliability for the preliminary instrument and suggested concurrent validity through associations with child functioning and parent responses to child pain [11
]. The second study by Wallace et al. [10
] aimed to further refine and examine the reliability and validity of the 24-item PPFQ (PPFQ-24). This resulted in a 17-item questionnaire (PPFQ-17) with four factors: (1) values-based action (VBA); (2) emotional acceptance (EA); (3) pain acceptance (PA); and (4) pain willingness (PW). The subscales and the full measure generally had adequate internal reliability (though weaker for the three-item PW subscale), and demonstrated adequate correlations with adolescent-reported measures of pain, functioning, pain acceptance, and distress. The authors concluded the PPFQ-17 to be a reasonably reliable and valid measure for clinical use and further research. However, it was also noted that the PA subscale, with few significant correlations and “no unique contributions within the measures included”, should be further investigated in future studies designed to test, for example, parental distress, which may result in a briefer measure excluding the PA subscale [10
]. Therefore, the objectives of the current study were to (1) explore the factor structure and reliability of the Swedish version of the PPFQ-17 in a sample of parents of children referred to a tertiary pain clinic for chronic pain; and (2) to investigate the concurrent validity of the PPFQ by analyzing its relation to parental distress (anxiety and depression) among parents of children and adolescents with chronic debilitating pain.
The present study assessed the adequacy of the Swedish translation of the PPFQ and evaluated the factor structure of the PPFQ-17 in a Swedish sample of 263 parents of children with chronic pain. Exploratory factor analysis with PCA supported a three-factor solution. Seven items were removed in an iterative process due to poorer extraction, significant cross loadings, or negative contributions to the overall reliability of the scale, resulting in a final version with 10 items. Notably, the three factors in the final version matched three of the four labels proposed by Wallace et al. perfectly and were retained. One of the factors, PA, was eliminated in the process, in line with author discussions in the first factor study [10
]. The suggested final version of the questionnaire has three theoretically discernible subscales: VBA, PW, and (EA) [10
], demonstrating fair to excellent internal consistencies. In addition, the PPFQ-10 correlated very strongly with the PPFQ-17 and was able to explain a significant amount of variance in parental anxiety and depression. Some differences regarding the subscales’ individual contributions were seen, where VBA and EA obtained significant beta coefficients, while PW did not. This result is in line with the study by Wallace et al. [10
], which described the PW subscale as “the most divergent from the total”, in the sense that it had unique correlations with other main variables included in that study which the other subscales did not have. Consequently, the results from the current study are promising in their similarity to the results by Wallace et al. [10
], and confirm the construct validity of the instrument when used in a different country and different language. The fact that the construct of parental psychological flexibility displays such consistency across samples and countries, points to the fact that parents’ distressing experiences in relation to their child’s pain may be of direct clinical importance. However, future studies should evaluate the psychometric properties and utility of the PPFQ-10 in different subgroups, cultures, and languages.
The levels of anxiety and depression were elevated in the current sample compared to Swedish and German normative samples [39
]. These results are consistent with previous research on parents of children with chronic pain [41
], and serve as yet another indication of pediatric chronic pain not only being a matter of the child, but also a family concern [42
], and further point to the need for targeted parental interventions in the specific context of pediatric chronic pain. For example, earlier studies on parental distress in pediatric chronic pain have reported parents feeling a lack of life control, being caught in a pattern of short-term avoidance behaviors, and unable to change a style of parenting that they know is not appropriate in relation to their child’s age [43
]. Although the correlation and regression analyses between parental distress and parental psychological flexibility in the current study had the primary objective of concurrent criteria validation, the results nevertheless provide further insight on the interrelation between these variables in parents of children with chronic pain. One possible explanation for the interrelationship seen in this study could be that lower psychological flexibility in a parent of a child with chronic pain potentially increases the risk for less adaptive and values incongruent parental behaviors, which may eventually lead to parental rumination and depression [17
There are, however, a number of limitations that need to be taken into account when interpreting the findings of the current study. With a cross-sectional design, the direction of causality between parental depression and psychological flexibility remains inconclusive. A second potential restriction is that all data are based on self-report and other sources of verification of psychiatric diagnoses of parents are lacking. Further research could, for example, make use of health care records to cross-check results for parental illness. Moreover, the choice of HADS as the sole variable for concurrent criterion validation is not comprehensive, and future validation analyses of the PPFQ-10 could benefit from using a broader set of measures, including parental acceptance, parental reactivity to the child’s pain, observational data on relevant parent and child interactions, and possibly also parental cognitive flexibility and executive function. Measures of parental encouragement of the child’s illness behavior could also be helpful in establishing discriminant validity. Furthermore, some differences between the subscales’ individual contributions were seen, and the relative merits of the subscales could benefit from further examination with other samples, in outcome studies as well as in mediation analyses. Also, longitudinal or experimental designs are required to evaluate the predictive utility of the instrument for child treatment outcomes, and also to establish if treatment interventions specifically targeted at increasing parental psychological flexibility may ultimately benefit both parent and child outcomes.
In conclusion, the factor structure and reliability of this revised and shortened version of the original PPFQ are supported within our results. Results also illustrate the importance of the PPFQ-10 in explaining variance in parental anxiety and depression, supporting criterion validity. Based on the existing data, the PPFQ-10 could serve as a useful tool to assess psychological inflexibility in parents of children with chronic pain, simultaneously reducing the burden of research and assessment.