Psychological Inflexibility and Child Anxiety.
Open accessAbstract
Psychological flexibility is the main outcome of acceptance commitment therapy. Insight into the usefulness of measuring psychological flexibility is an important step to enable studies on the effectiveness of acceptance commitment therapy in middle-aged children (8-10 years). For this purpose, we examined the factor structure, the construct validity and the reliability of the Avoidance and Fusion Questionnaire for Youth. The Avoidance and Fusion Questionnaire for Youth taps psychological inflexibility (the opposite of psychological flexibility) in children and adolescents. Although the questionnaire has been extensively validated in older children, this is not the case for middle-aged children. The Avoidance and Fusion Questionnaire for Youth contains 17 items and is constituted of the subscales cognitive fusion, experiential avoidance and behavioral ineffectiveness. A shortened 8-item version also exists, the Avoidance and Fusion Questionnaire for Youth-8, which does not distinguish between these subscales. We performed a confirmatory factor analysis. Additionally, we assessed the relationship between psychological flexibility and child anxiety. Children, aged 8-10 years, were recruited via regular primary schools. Of the 459 approached children, 267 (58 %) parents signed informed consents for their children (Age: M = 9.18; SD = .79; Sex: n = 137, 51 %). Children completed the questionnaires during regular classes. In this sample, the 17-item version of the Avoidance and Fusion Questionnaire for Youth was less appropriate for measuring psychological inflexibility than the 8-item version. Furthermore, we found a significant positive relationship between psychological inflexibility and child anxiety. We argue that acceptance commitment therapy would be an interesting candidate for intervening early on in dysfunctional child anxiety, as acceptance commitment therapy's cognitive elements require cognitive skills that children are likely to master early on.
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Claims the paper makes
5 of 23 cited sources checked · 3 supported · 0 flagged · accuracy not yet measured
- Findingown data
Internal consistencies of the AFQ-17 subscales cognitive fusion, experiential avoidance, and inaction/behavioral ineffectiveness were adequate.
“The internal consistencies of the AFQ-17 subscales cognitive fusion, experiential avoidance, and inaction or behavioral ineffectiveness were adequate, with α = .76, α = .72, and α = .75, respectively.”
Quote in the paperNot a substantial claim - Findingown data
The one-factor model for the 17-item AFQ-Y yielded fit values closely resembling those of the three-factor model.
“The more parsimonious one-factor model yielded fit values closely resembling those of the three-factor model (χ² = 229, df = 101; χ²/df = 2.2; CFI = .900, TLI = .886, RMSEA = .066).”
Quote in the paperSubstantial claim - Findingown data
The one-factor structure of the shortened AFQ-Y8 fits the data well according to all fit criteria.
“However, the one-factor structure of the shortened AFQ-Y, the AFQ-Y8, fits the data well according to all fit criteria (χ² = 35, df = 20; χ²/df = 1.8; CFI = .969, TLI = .957, RMSEA = .054).”
Quote in the paperSubstantial claim - Findingown data
Children with clinical-range anxiety scores had higher scores than normal-range children on psychological inflexibility measured with 17 items.
“on psychological inflexibility measured with 17 items (clinical scores: M = 21.82, SD = 13.25; non-clinical scores: M = 17.17, SD = 12.52), t(265) = −2.71, p = .007”
Quote in the paperSubstantial claim - Findingown data
Children with clinical-range anxiety scores had higher scores than normal-range children on inaction or behavioral ineffectiveness.
“on inaction or behavioral ineffectiveness, (clinical scores: M = 7.54, SD = 5.28; non-clinical scores: M = 5.41, SD = 4.56), t(265) = −3.31, p = .001”
Quote in the paperSubstantial claim
- Findingown data
The three-factor model for the 17-item AFQ-Y did not fit the correlation structure well according to all fit criteria.
“First the three-factor model for the AFQ-Y, derived from three subscales Cognitive fusion, Experiential avoidance, and Inaction of behavioral ineffectiveness (using all 17 items), did not fit the correlation structure well according to all fit criteria (χ² = 245, df = 116; χ²/df = 2.1; CFI = .908, TLI = .892, RMSEA = .065).”
Quote in the paperSubstantial claim - Findingown data
Internal consistencies of the total AFQ-17 and AFQ-8 were adequate to good.
“The internal consistencies of the total score psychological inflexibility measured with the AFQ-17 total scale and the eight items of the short version AFQ-8 were also adequate to good, with α = .89 and α = .79, respectively.”
Quote in the paperNot a substantial claim - Findingown data
Cronbach's alpha did not increase if any AFQ-17 item was deleted.
“Cronbach’s α did not increase if an item of any of the AFQ-17 was deleted.”
Quote in the paperNot a substantial claim - Findingown data
Children with clinical-range anxiety scores had higher scores than normal-range children on psychological inflexibility measured with 8 items.
“and on psychological inflexibility measured with 8 items (clinical scores: M = 8.73, SD = 6.21; non-clinical scores: M = 6.69, SD = 5.79), t(265) = −2.57, p = .01.”
Quote in the paperSubstantial claim - Findingown data
Children with SCARED-71 anxiety scores above the clinical cut-off had higher scores than children with scores within the normal range on experiential avoidance.
“children with SCARED-71 anxiety scores above the clinical cut-off (n = 78), had higher scores than children with scores within the normal range (n = 189) on experiential avoidance (clinical scores: M = 6.60, SD = 4.29; non-clinical scores: M = 5.47, SD = 4.25), t(265) = −1.98, p = .048”
Quote in the paperSubstantial claim - Findingown data
The three-factor model cannot be seen as an improvement over the one-factor model for the 17-item AFQ-Y.
“Testing the difference between these models using the chi-square difference test (Δχ² = 16, df = 15; p = .382) shows that the three-factor model cannot be seen as an improvement over the one-factor model.”
Quote in the paperSubstantial claim - Premisecitation
Anxiety disorders are the most prevalent type of psychiatric disorders in children.
“First, anxiety disorders are the most prevalent type of psychiatric disorders in children (Cartwright-Hatton et al. 2006).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Cartwright-Hatton et al. 2006 source
- Interpretationown data
The 17-item AFQ-Y is less appropriate for measuring psychological inflexibility than the 8-item AFQ-Y8 in middle-aged children.
“In this sample, the 17-item version of the Avoidance and Fusion Questionnaire for Youth was less appropriate for measuring psychological inflexibility than the 8-item version.”
Quote in the paperSubstantial claim- Rests on an assumption: Scores on the eight AFQ-Y8 items extracted from the 17-item AFQ-Y are equivalent to administering the AFQ-Y8 separately.
- Interpretationown data
The AFQ-Y8 measures psychological inflexibility equally well in boys and girls.
“We found comparable results for the factor structure of the AFQ-Y8 in boys and in girls, which means that the questionnaire taps psychological inflexibility equally well in boys and girls”
Quote in the paperSubstantial claim - Premisecitation
Anxiety disorders have an early age of onset, with a median age of onset of 11 years.
“Second, compared to other types of psychopathology, anxiety disorders have an early age of onset, with a median age of onset of 11 years (Kessler et al. 2005).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Kessler et al. 2005 source
- Premisecitation
The AFQ-Y has been extensively validated in children aged 10 years and older.
“The AFQ-Y has been extensively validated in children aged 10 years and older (Greco et al. 2008).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Greco et al. 2008 source
- Premisecitation
Changing the content of cognitions, as in traditional CBT, requires hypothetico-deductive reasoning skills.
“Changing the content of cognitions, as is done in traditional CBT, however, requires hypothetico-deductive reasoning skills (Kendall, Reber et al. 1990; Ronen 1997).”
Quote in the paperSubstantial claim0 of 2 sources checked- cites Kendall, Reber et al. 1990 source
- cites Ronen 1997
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Premisecitation
Formal operational reasoning develops from 11 years of age onward.
“This constitutes a form of abstract reasoning consistent with Piaget’s stage of formal operational reasoning, which children develop from 11 years of age onwards.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Piaget
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Interpretationown data
It is not valid to distinguish between cognitive fusion, experiential avoidance, and behavioral ineffectiveness in children aged 11 years and younger.
“These findings indicate that it would not be valid to distinguish between cognitive fusion, experiential avoidance and behavioral ineffectiveness in children aged 11 years and younger”
Quote in the paperSubstantial claim - Premisecitation
Intervening via the child rather than via parents seems to lead to the most favorable outcomes when treating child anxiety.
“research shows that intervening via the child (instead of via parents) seems to lead to the most favorable outcomes when treating child anxiety (Simon et al. in preparation; Thulin et al. 2014).”
Quote in the paperSubstantial claim0 of 2 sources checked- cites Simon et al. in preparation
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- cites Thulin et al. 2014 source
- Premisecitation
Children can interpret metaphors from 7 years of age onward.
“Children are capable of interpreting metaphors from 7 years of age onward (Billow 1981; McCurry and Hayes 1992)”
Quote in the paperSubstantial claim0 of 2 sources checked - Premisecitation
Children are generally capable of completing self-report questionnaires from age 7 onward.
“Children are generally capable to complete self-report questionnaires from the age of 7 years onward (Beesdo et al. 2009; Langley et al. 2002; Myers and Winters 2002).”
Quote in the paperSubstantial claim0 of 3 sources checked - Interpretationreasoning
The contrast between panic disorder and specific phobia could explain their different relation to psychological inflexibility.
“The contrast between these disorders could explain their different relation to psychological inflexibility.”
Quote in the paperSubstantial claim - Interpretationown data
The higher psychological inflexibility scores in children with clinical-range anxiety could be a first indication of treatment sensitivity of the measure for children with anxiety.
“This could be a first indication of treatment sensitivity of the measure psychological flexibility for children with anxiety.”
Quote in the paperSubstantial claim - Interpretationreasoning
The AFQ-Y8 is likely more appropriate for middle-aged children than the 17-item version because of the complexity of the questions and answering categories.
“We found that the AFQ-Y8 is likely to be more appropriate for this age group than the 17-item version. This is probably due to the complexity of the questions and the complexity of the answering categories.”
Quote in the paperSubstantial claim- Rests on an assumption: Scores on the eight AFQ-Y8 items extracted from the 17-item AFQ-Y are equivalent to administering the AFQ-Y8 separately.
- Study design and conductown data
The small number of missing items and large sample size make it unlikely that more complex methods would change parameter estimates appreciably.
“Because of the large sample size and the small number of missing items, more complex methods were unlikely to change parameter estimates appreciably.”
Quote in the paperNot a substantial claim - Interpretationreasoning
The study was performed in a community sample, which limits generalizability of the findings to clinical populations.
“the fact that this study was performed in a community population hinders the generalizability of the findings to clinical populations.”
Quote in the paperNot a substantial claim
- Classified as probably not a substantial claim. 14
- May combine two claims. 10
- The quote only partly states this claim. 1
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationACT has been shown to be effective for several adult psychopathologies, including anxiety disorders.
“In recent years, ACT has gained much attention and has proven effective for various types of adult psychopathology (Hayes et al. 2006), such as anxiety disorders (Swain et al. 2013).”
Quote in the paperNot a substantial claim2 of 2 sources checked- cites Hayes et al. 2006 source
The Discussion (p. 21) says ACT seems to be working across a broad range of problems, supporting the claim of effectiveness across types of psychopathology. But it describes the evidence as young, and the outcomes review (p. 17) says no firm conclusions should be reached from the preliminary data. Thus “proven effective” overstates this source’s conclusion. The citing sentence attaches the anxiety-disorders example to Swain et al. (2013), not to Hayes et al. (2006). (LLM, conf=0.86)
Experimental — accuracy not yet measured - cites Swain et al. 2013 source
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationPsychological flexibility is the primary outcome of acceptance and commitment therapy.
“The hallmark feature of ACT and thus its most important outcome is psychological flexibility (Hayes et al. 2006).”
Quote in the paperNot a substantial claim1 of 1 sources checked- cites Hayes et al. 2006 source
May combine two claims.
PremisecitationThe SCARED-R has good internal consistency, satisfactory test-retest reliability, and discriminates well between anxiety problems and other behavioral problems.
“The SCARED-R possesses good internal consistency for total and subscales scores (Muris et al. 2004; Muris et al. 2001; Muris et al. 1999b), satisfactory test–retest reliability (Muris et al. 1999) and discriminates well between anxiety problems and other behavioral problems (Muris et al. 2004).”
Quote in the paperNot a substantial claim1 of 3 sources checked- cites Muris et al. 2004 source
- cites Muris et al. 2001 source
- cites Muris et al. 1999b source
In the citing sentence, this paper is cited for satisfactory test–retest reliability. The available indexed passages contain only the title and bibliographic metadata, with no findings on test–retest reliability; a search for that term returned no results passage. The claim cannot be checked against our copy. (LLM, conf=0.73)
Experimental — accuracy not yet measured
May combine two claims.
PremisecitationThe SCARED-71 is a useful anxiety screening tool in primary school children, discriminating between children with and without anxiety disorders and predicting separation anxiety disorder, social phobia, and specific phobia.
“The SCARED-71 was found to be a useful anxiety screening tool in primary school children, because the instrument discriminates between children with and without an anxiety disorders and predicts specifically separation anxiety disorder, social phobia and specific phobia (Simon and Bögels 2009).”
Quote in the paperNot a substantial claim1 of 1 sources checked- cites Simon and Bögels 2009 source
May combine two claims.
Findingown dataThe correlation between psychological inflexibility and anxiety symptoms was modest but significant.
“The correlation between psychological inflexibility and anxiety symptoms was modest, but significant, r(265) = .27, p < .01.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Findingown dataThe homogeneity of the SCARED-71 in this study was good.
“The homogeneity of the SCARED-71 in this study was good, with α = .96 for the total score and α ranging from .80 to .87 for the subscales.”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataChildren with clinical-range anxiety scores scored higher, although not significantly, on cognitive fusion.
“Children with scores within the clinical range also scored higher, although not significant, on cognitive fusion, (clinical scores: M = 7.68, SD = 5.70; non-clinical scores: M = 6.30, SD = 5.13), t(265) = −1.93, p = .054.”
Quote in the paperNot a substantial claimThe quote only partly states this claim.
Findingown dataThe one-factor structure of the AFQ-Y8 is similar for boys and girls, as shown by configural, metric, and scalar invariance.
“These results imply that the one-factor structure for the AFQ-Y is similar for boys and girls.”
Quote in the paperSubstantial claimMay combine two claims.
FindingreasoningThe relationship between anxiety symptoms and psychological inflexibility was strongest for panic disorder and lowest for social and specific phobia.
“Finally, the relationship between symptoms of anxiety and psychological inflexibility was found to be the strongest for panic disorder and the lowest for social and specific phobia.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationThe AFQ-Y has good construct validity and high reliability in prior validation.
“Greco et al. (2008) showed a good construct validity of the AFQ-Y, as well as a high reliability (α = .90).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Greco et al. 2008 source
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThe Dutch version of the AFQ-Y was constructed by translation and back-translation performed by qualified translators.
“The Dutch version of the AFQ-Y was constructed by translation and back-translation performed by qualified translators.”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationResearch on ACT's effectiveness in children is limited and based on small studies, but results are generally promising.
“Studies on ACT’s effectiveness in children are scarce and smaller-scaled (e.g., Heffner et al. 2002) but generally show promising results (Coyne et al. 2011).”
Quote in the paperNot a substantial claim0 of 2 sources checkedProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataParents provided active informed consent for their children to participate.
“Of the 459 approached children, 267 (58 %) parents signed informed consents for their children”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThe study was approved by the local ethical committee.
“This cross-sectional study was approved by the local ethical committee.”
Quote in the paperNot a substantial claimMay combine two claims.
Study design and conductnone givenThe study did not collect information on the possible presence of anxiety disorders, but only used a questionnaire to measure symptoms of anxiety.
“We did not collect information on the possible presence of anxiety disorders, but only used a questionnaire to measure symptoms of anxiety in children.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThe study did not collect information on possible comorbid difficulties, such as depression.
“In addition, we did not collect any information on possible comorbid difficulties, such as depression.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S2 (checkable).
InterpretationreasoningChildren with anxiety could profit from targeting their psychological inflexibility, which is done in ACT.
“Children with anxiety could thus profit from targeting their psychological inflexibility, which is done in ACT.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenMissing values were replaced by the item's median, a relatively unsophisticated strategy.
“we replaced the missing values by the item’s median, which can be considered as a relatively unsophisticated strategy of replacing missing items.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S4 (based). May combine two claims.
Premisenone givenACT contains cognitive elements that require metacognitive reasoning skills, which middle-aged children master.
“ACT contains cognitive elements that require metacognitive reasoning skills, which middle-aged children master.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataThe validity of the AFQ-Y8 was not tested separately; scores were distilled from the completed 17-item AFQ-Y.
“we did not test the validity of the AFQ-Y8 separately, but, instead, distilled the scores on the items from the completed 17-item versions of the AFQ-Y.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S2 (checkable).
InterpretationreasoningACT is an interesting candidate for diminishing symptoms of dysfunctional child anxiety in middle-aged children.
“This makes ACT an interesting candidate for diminishing symptoms of dysfunctional child anxiety in middle-aged children.”
Quote in the paperNot a substantial claim- Rests on an assumption: Scores on the eight AFQ-Y8 items extracted from the 17-item AFQ-Y are equivalent to administering the AFQ-Y8 separately.
Probably not a substantial claim: may not pass S4 (based). May combine two claims.
Premisenone givenTraditional CBT contains cognitive elements that require abstract reasoning skills, which children acquire from eleven years of age onward.
“Traditional CBT, however, contains cognitive elements that require abstract reasoning skills, which children acquire from eleven years of age onward.”
Quote in the paperNot a substantial claim
The paper relies on this without support.
Information on the usefulness of applying the AFQ-Y in children younger than 10 is lacking.
“To date, information on the usefulness of applying the questionnaire in these younger children is lacking.”
The paper relies on this without support.
Scores on the eight AFQ-Y8 items extracted from the 17-item AFQ-Y are equivalent to administering the AFQ-Y8 separately.
“we did not test the validity of the AFQ-Y8 separately, but, instead, distilled the scores on the items from the completed 17-item versions of the AFQ-Y.”
The paper relies on this without support.
The sample of children recruited via regular primary schools is representative of middle-aged children in the Netherlands.
“Children, aged 8–10 years, were recruited via regular primary schools in the Netherlands.”
Statistics recomputed
Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.
- Consistentt(265) = -1.91reported p = .06 · recomputed p = .057
“t(265) = −1.91, p = .06”
- Consistentr(265) = 0.27reported p < .01 · recomputed p < .001
“r(265) = .27, p < .01”
- Consistentt(265) = -1.98reported p = .048 · recomputed p = .049
“t(265) = −1.98, p = .048”
- Consistentt(265) = -3.31reported p = .001 · recomputed p = .001
“t(265) = −3.31, p = .001”
- Consistentt(265) = -2.71reported p = .007 · recomputed p = .007
“t(265) = −2.71, p = .007”
- Consistentt(265) = -2.57reported p = .01 · recomputed p = .011
“t(265) = −2.57, p = .01”
- Consistentt(265) = -1.93reported p = .054 · recomputed p = .055
“t(265) = −1.93, p = .054”
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Model described as more parsimonious has fewer degrees of freedom
MinorFor the two models fitted to the same 17 items, the one-factor model is called more parsimonious but has 101 degrees of freedom, versus 116 for the three-factor model. Fewer degrees of freedom indicate more freely estimated parameters, not a more parsimonious model.
“The more parsimonious one-factor model yielded fit values closely resembling those of the three-factor model (χ² = 229, df = 101; χ²/df = 2.2; CFI = .900, TLI = .886, RMSEA = .066).”
“the three-factor model for the AFQ-Y, derived from three subscales Cognitive fusion, Experiential avoidance, and Inaction of behavioral ineffectiveness (using all 17 items), did not fit the correlation structure well according to all fit criteria (χ² = 245, df = 116; χ²/df = 2.1; CFI = .908, TLI = .892, RMSEA = .065).”
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MethodKessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005) · Archives of General Psychiatry · doi:10.1001/archpsyc.62.6.593 · Cited by 20,391 · cited 1× · see citing works
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Acceptance and commitment therapy: model, processes and outcomes
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BackgroundA checklist for testing measurement invariance
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“Keywords Child anxiety ● Psychological flexibility ● Acceptance and commitment therapy ● Cognitive level ● Avoidance and Fusion Questionnaire for Youth (AFQ-Y)”
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“Psychological flexibility (the opposite of psychological inflexibility) entails pursuing important values and goals by choosing behavior in line with these values, while accepting (unpleasant) experiences (Hayes and Strosahl 2004).”
BackgroundAnxiety in a neglected population: Prevalence of anxiety disorders in pre-adolescent children
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“However, studies on psychological flexibility, ACT’s main outcome measure, in children are scarce, especially in middle-aged children (Greco et al. 2008).”
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“The SCARED-R possesses good internal consistency for total and subscales scores (Muris et al. 2004; Muris et al. 2001; Muris et al. 1999b), satisfactory test–retest reliability (Muris et al. 1999) and discriminates well between anxiety problems and other behavioral problems (Muris et al. 2004).”
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“Finally, child anxiety is an important candidate for preventive interventions, not only because of its high prevalence and its early age of onset, but also because of its negative effects on the quality of life (Achenbach et al. 1995), its high homo- and heterotypic continuity (Simon et al.”
BackgroundAcceptance and Commitment Therapy in the treatment of anxiety: A systematic review
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“Keywords Child anxiety ● Psychological flexibility ● Acceptance and commitment therapy ● Cognitive level ● Avoidance and Fusion Questionnaire for Youth (AFQ-Y)”
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“Indeed, Fledderus et al. (2010) concluded that a preventive ACT intervention was successful at improving positive mental health by increasing psychological flexibility.”
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“…for preventive interventions, not only because of its high prevalence and its early age of onset, but also because of its negative effects on the quality of life (Achenbach et al. 1995), its high homo- and heterotypic continuity (Simon et al. 2014), and its high societal costs (Bodden et al. 2008).”
BackgroundMYERS, K., & WINTERS, N. C. (2002) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1097/00004583-200202000-00004 · Cited by 180 · cited 2× · see citing works
“Keywords Child anxiety ● Psychological flexibility ● Acceptance and commitment therapy ● Cognitive level ● Avoidance and Fusion Questionnaire for Youth (AFQ-Y)”
BackgroundCoyne, L. W., McHugh, L., & Martinez, E. R. (2011) · Child and Adolescent Psychiatric Clinics of North America · doi:10.1016/j.chc.2011.01.010 · Cited by 168 · cited 2× · see citing works
“2002) but generally show promising results (Coyne et al. 2011).”
BackgroundHeffner, M., Sperry, J., Eifert, G. H., & Detweiler, M. (2002) · Cognitive and Behavioral Practice · doi:10.1016/s1077-7229(02)80053-0 · Cited by 162 · cited 2× · see citing works
“Keywords Child anxiety ● Psychological flexibility ● Acceptance and commitment therapy ● Cognitive level ● Avoidance and Fusion Questionnaire for Youth (AFQ-Y)”
BackgroundObserving spontaneous metaphor in children
Billow, R. M. (1981) · Journal of Experimental Child Psychology · doi:10.1016/0022-0965(81)90028-x · Cited by 156 · cited 2× · see citing works
“Children are capable of interpreting metaphors from 7 years of age onward (Billow 1981; McCurry and Hayes 1992), and the use of metaphors in children is empirically supported (Heffner et al.”
BackgroundMuris, P., Merckelbach, H., Van Brakel, A., & Mayer, A. B. (1999) · Anxiety, Stress & Coping · doi:10.1080/10615809908249319 · Cited by 142 · cited 2× · see citing works
“The SCARED-R possesses good internal consistency for total and subscales scores (Muris et al. 2004; Muris et al. 2001; Muris et al. 1999b), satisfactory test–retest reliability (Muris et al. 1999) and discriminates well between anxiety problems and other behavioral problems (Muris et al. 2004).”
BackgroundThe trouble with language: Experiential avoidance, rules, and the nature of verbal events
Hayes, S. C., & Gifford, E. V. (1997) · Psychological Science · doi:10.1111/j.1467-9280.1997.tb00405.x · Cited by 131 · cited 1× · see citing works
“…(Luoma and Hayes 2003) has been defined as “the entanglement with the content of private events” (Greco et al. 2008) and experiential avoidance (Hayes and Gifford 1997) as “the unwillingness to experience certain private events and attempts to avoid, manage, alter, or otherwise control their…”
BackgroundMuris, P., Dreessen, L., Bögels, S., Weckx, M., & van Melick, M. (2004) · Journal of Child Psychology and Psychiatry · doi:10.1111/j.1469-7610.2004.00274.x · Cited by 129 · cited 3× · see citing works
“The SCARED-R possesses good internal consistency for total and subscales scores (Muris et al. 2004; Muris et al. 2001; Muris et al. 1999b), satisfactory test–retest reliability (Muris et al.”
BackgroundThe Effect of Parent Involvement in the Treatment of Anxiety Disorders in Children: A Meta-Analysis
Thulin, U., Svirsky, L., Serlachius, E., Andersson, G., & Öst, L.-G. (2014) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2014.923928 · Cited by 124 · cited 2× · see citing works
“Third, forwarding children as active change agents in their therapy is of specific importance for child anxiety, as research shows that intervening via the child (instead of via parents) seems to lead to the most favorable outcomes when treating child anxiety (Simon et al. in preparation; Thulin et al. 2014).”
BackgroundMuris, P., Mayer, B., Bartelds, E., Tierney, S., & Bogie, N. (2001) · British Journal of Clinical Psychology · doi:10.1348/014466501163724 · Cited by 118 · cited 1× · see citing works
“The SCARED-R possesses good internal consistency for total and subscales scores (Muris et al. 2004; Muris et al. 2001; Muris et al. 1999b), satisfactory test–retest reliability (Muris et al. 1999) and discriminates well between anxiety problems and other behavioral problems (Muris et al. 2004).”
BackgroundThe diagnostic utility of the Screen for Child Anxiety Related Emotional Disorders-71 (SCARED-71)
Bodden, D. H. M., Bögels, S. M., & Muris, P. (2009) · Behaviour Research and Therapy · doi:10.1016/j.brat.2009.01.015 · Cited by 117 · cited 5× · see citing works
“Completing the questionnaires took the children approximately 25 min.”
BackgroundMethodInfluentialCognitive-behavioral treatment of conduct-disordered children
Kendall, P. C., Reber, M., McLeer, S., Epps, J., & Ronan, K. R. (1990) · Cognitive Therapy and Research · doi:10.1007/bf01183997 · Cited by 88 · cited 1× · see citing works
“Keywords Child anxiety ● Psychological flexibility ● Acceptance and commitment therapy ● Cognitive level ● Avoidance and Fusion Questionnaire for Youth (AFQ-Y)”
BackgroundFergus, T. A., Valentiner, D. P., Gillen, M. J., Hiraoka, R., Twohig, M. P., Abramowitz, J. S., & McGrath, P. B. (2012) · Psychological Assessment · doi:10.1037/a0025776 · Cited by 68 · cited 1× · see citing works
“Testing the difference between these models using the chi-square difference test (Δχ²= 16, df= 15; p= .382) shows that the three-factor model cannot be seen as an improvement over the a AFQ-17: Avoidance fusion questionnaire (17 items) b SCARED-71: Screen for child anxiety related emotional…”
MethodScreening for anxiety disorders in children
Simon, E., & Bögels, S. M. (2009) · European Child & Adolescent Psychiatry · doi:10.1007/s00787-009-0023-x · Cited by 64 · cited 4× · see citing works
“Although the SCARED-71 has been validated (Bodden et al. 2009) and has been found to be predictive of anxiety disorders (Simon and Bögels 2009), the use of a diagnostic measure would provide more insight into the severity and the level of dysfunction of the child’s anxiety.”
BackgroundMethodInfluentialSelf-citationCognitive Developmental Therapy With Children
Ronen, T., & Friedberg, R. D. (1998) · Journal of Cognitive Psychotherapy · doi:10.1891/0889-8391.12.4.343 · Cited by 61 · cited 1× · see citing works
“Changing the content of cognitions, as is done in traditional CBT, however, requires hypothetico-deductive reasoning skills (Kendall, Reber et al. 1990; Ronen 1997).”
MethodAssessment of childhood anxiety
Langley, A. K., Bergman, R. L., & Piacentini, J. C. (2002) · International Review of Psychiatry · doi:10.1080/09540260220132626 · Cited by 49 · cited 2× · see citing works
“Keywords Child anxiety ● Psychological flexibility ● Acceptance and commitment therapy ● Cognitive level ● Avoidance and Fusion Questionnaire for Youth (AFQ-Y)”
BackgroundACT with Children, Adolescents, and Their Parents
Murrell, A. R., Coyne, L. W., & Wilson, K. G. (2004) · A Practical Guide to Acceptance and Commitment Therapy · doi:10.1007/978-0-387-23369-7_10 · Cited by 45 · cited 2× · see citing works
“For this purpose, metaphors are used extensively instead of literal instructions (Murrell et al. 2004).”
BackgroundMethodClinical and experimental perspectives on metaphorical talk
McCurry, S. (1992) · Clinical Psychology Review · doi:10.1016/0272-7358(92)90023-2 · Cited by 45 · cited 2× · see citing works
“Children are capable of interpreting metaphors from 7 years of age onward (Billow 1981; McCurry and Hayes 1992), and the use of metaphors in children is empirically supported (Heffner et al.”
BackgroundHeffner, M., Greco, L. A., & Eifert, G. H. (2003) · Child & Family Behavior Therapy · doi:10.1300/j019v25n01_02 · Cited by 26 · cited 1× · see citing works
“Children are capable of interpreting metaphors from 7 years of age onward (Billow 1981; McCurry and Hayes 1992), and the use of metaphors in children is empirically supported (Heffner et al. 2003).”
Backgroundindicated, N. A. (1992) · Contemporary Psychology: A Journal of Reviews · doi:10.1037/032287 · Cited by 19 · see citing works
Acceptance and commitment therapy: empirical considerations.
Rector, N. A. (2013) · Behavior Therapy · doi:10.1016/j.beth.2010.07.007 · Cited by 18 · cited 2× · see citing works
“Keywords Child anxiety ● Psychological flexibility ● Acceptance and commitment therapy ● Cognitive level ● Avoidance and Fusion Questionnaire for Youth (AFQ-Y)”
BackgroundAnxiety in Preadolescent Children: What Happens If We Don't Treat It, and What Happens If We Do?
Simon, E., van der Sluis, C. M., Muris, P., Thompson, E. J., & Cartwright‐Hatton, S. (2014) · Psychopathology Review · doi:10.5127/pr.035213 · Cited by 11 · cited 2× · see citing works
“Keywords Child anxiety ● Psychological flexibility ● Acceptance and commitment therapy ● Cognitive level ● Avoidance and Fusion Questionnaire for Youth (AFQ-Y)”
BackgroundSelf-citation(2011) · Computer Fraud & Security · doi:10.1016/s1361-3723(11)70105-1 · Cited by 6 · see citing works
Theoretische achtergronden van ACT
Groot, F. D., Corthouts, J., A-Tjak, J. G. L., et al. (2015) · Bohn Stafleu van Loghum eBooks · doi:10.1007/978-90-368-0497-4_1 · Cited by 1 · cited 8× · see citing works
“ACT’s main purpose is to improve a person’s quality of life, rather than to reduce the person’s symptomatology as is the case in traditional Cognitive behavioral therapy (CBT).”
BackgroundInfluentialTheoretische achtergronden van ACT
Groot, F., Kleen, M., & Rokx, A. T. A. J. J. (n.d.) · Acceptance & Commitment Therapy · doi:10.1007/978-90-313-6320-9_1
Flagged first, then by citations
Research works printed but not linked: 2
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- Luoma, J., & Hayes, S. C. (2003). Cognitive defusion. In W. T. Donohue, J. E. Fisher & S. C. Hayes (Eds.), Empirically supported techniques for cognitive behavior therapy: A step by step guide for clinicians. New York: Wiley.
Cited by
Sorted by citations
Tyndall, I., Waldeck, D., Pancani, L., Whelan, R., Roche, B., & Pereira, A. (2020) · Behavior Modification · doi:10.1177/0145445518820036 · Cited by 104 · see citing works
Catalán, E. L., Pereira, A. F. L., Vilalta, D. C., & Pérez, A. J. (2026) · Cultura Ciencia y Deporte · doi:10.12800/ccd · Cited by 97 · see citing works
Associations between depression, anxious arousal and manifestations of psychological inflexibility
Gilbert, K. E., Tonge, N. A., & Thompson, R. J. (2019) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2018.09.006 · Cited by 53 · see citing works
Adaptability and psychological flexibility: Overlapping constructs?
Waldeck, D., Pancani, L., Holliman, A. J., Karekla, M., & Tyndall, I. T. (2021) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2021.01.002 · Cited by 58 · see citing works
Muris, P., Meesters, C., Herings, A., Jansen, M., Vossen, C., & Kersten, P. (2017) · Mindfulness · doi:10.1007/s12671-017-0714-1 · Cited by 45 · see citing works
“In addition, the AFQ-Y has also been shown to correlate positively with measures of psychopathological symptoms (Greco et al. 2008; Feinstein et al. 2011; Fergus et al. 2012; Livheim et al. 2016; Paulus et al. 2016; Simon and Verboon 2016; Valdivia-Salas et al. in press; Venta et al. 2012), although it should be noted…”
BackgroundMethodInfluentialThe Co-occurrence of Pediatric Chronic Pain and Anxiety
Mano, K. E. J., O’Bryan, E. M., Gibler, R. C., & Beckmann, E. A. (2019) · Clinical Journal of Pain · doi:10.1097/ajp.0000000000000763 · Cited by 37 · see citing works
Emerson, L.-M., Ogielda, C., & Rowse, G. (2019) · Frontiers in Psychology · doi:10.3389/fpsyg.2019.00262 · Cited by 34 · see citing works
García-Gómez, M., Guerra, J., López-Ramos, V. M., & Mestre, J. M. (2019) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph16234687 · Cited by 33 · see citing works
“Therefore, psychological inflexibility (PI) would be the opposite pole of the same dimension and, consequently, would have the opposite outcomes to those reported above [9,10].”
MethodResultBelinchón-deMiguel, P., Ruisoto, P., & Clemente‐Suárez, V. J. (2019) · Journal of Medical Systems · doi:10.1007/s10916-019-1188-6 · Cited by 29 · see citing works
Tracey, D., Gray, T. L., Truong, S., & Ward, K. S. (2018) · Frontiers in Psychology · doi:10.3389/fpsyg.2018.01565 · Cited by 26 · see citing works
García‐Rubio, C., Herrero, M., Jarillo, T. L., Albert, J., & Rodríguez‐Carvajal, R. (2023) · Journal of School Psychology · doi:10.1016/j.jsp.2023.04.001 · Cited by 30 · see citing works
Improving flexible parenting with Acceptance and Commitment Therapy: A case study
Flujas-Contreras, J. M., & Gómez, I. (2018) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2018.02.006 · Cited by 20 · see citing works
Psychometric properties of the Avoidance and Fusion Questionnaire – Youth in Colombia
Salazar, D. M., Ruiz, F. J., Suárez-Falcón, J. C., Barreto-Zambrano, M. L., Gómez-Barreto, M. P., & Flórez, C. L. (2019) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2018.11.008 · Cited by 18 · see citing works
Factors Influencing Adolescent Anxiety: The Roles of Mothers, Teachers and Peers
Chen, X., Li, M., Gong, H., Zhang, Z., & Wang, W. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph182413234 · Cited by 16 · see citing works
“Higher maternal psychological flexibility is related to adolescents’ psychological health and other positive psychological qualities, which can help adolescents resist excessive worry under stressful situations [68].”
BackgroundAndreu, C. I., & García‐Rubio, C. (2019) · Springer eBooks · doi:10.1007/978-3-030-25513-8_9 · Cited by 17 · see citing works
Pan, B., Wang, Y., Xu, P., Gong, Y., Zhao, C., Miao, J., & Li, Y. (2024) · BMC Psychology · doi:10.1186/s40359-024-02291-7 · Cited by 17 · see citing works
Effectiveness of Acceptance and Commitment Therapy on Mental Health Issues: A Systematic Review
Aravind, A., Agarwal, M., Malhotra, S., & Ayyub, S. (2024) · Annals of Neurosciences · doi:10.1177/09727531241300741 · Cited by 16 · see citing works
Torres-Fernández, G., Rodríguez‐Valverde, M., Reyes-Martín, S., & López, M. H. (2022) · Behavioral Sciences · doi:10.3390/bs12070201 · Cited by 14 · see citing works
Ning, M., Chen, Q., Li, Y., & Huang, C. (2024) · Child Psychiatry & Human Development · doi:10.1007/s10578-024-01720-3 · Cited by 11 · see citing works
“Some evidence supports that psychological inflexibility mediates the relation between adverse childhood experiences and mental disorders [25, 30, 39], but no similar findings for psychological flexibility (PF).”
Keulen, J., Matthijssen, D., Schraven, J., Deković, M., & Bodden, D. H. M. (2023) · BMC Psychiatry · doi:10.1186/s12888-023-04535-z · Cited by 11 · see citing works
“, the AFQ-Y-8), which also has adequate psychometric properties [68, 69].”
BackgroundMethod(2021) · doi:10.1093/oxfordhb/9780197550076.013.9 · Cited by 15 · see citing works
Cortical arousal and central nervous system fatigue after a mountain marathon
Clemente‐Suárez, V. J. (2017) · Cultura Ciencia y Deporte · doi:10.12800/ccd.v12i35.886 · Cited by 10 · see citing works
The relationship between test anxiety, rumination, and psychological flexibility
Doğan, U. (2023) · Current Psychology · doi:10.1007/s12144-023-04411-9 · Cited by 12 · see citing works
“…- ibility and anxiety have a favorable relationship (Berryhill et al., 2018 ; Davis et al., 2020; Gallego et al., 2020; Huang et al., 2021; Landi et al., 2020; Masuda et al., 2014; Masuda & Tully, 2012 ; Simon & Verboon, 2016; Tavakoli et al., 2019; Tirch et al., 2012 ; Wielgus et al., 2020).”
Wu, W., Kaur, A., Liang, Q. H., Xu, K., Mei, S., Ye, M., & Chen, L. (2023) · Journal of Child and Family Studies · doi:10.1007/s10826-023-02626-9 · Cited by 7 · see citing works
“For example, supporters of social cognitive theory (Bandura & Walters, 1977; Simon & Verboon, 2016) argue that observational learning is the most familiar manner of the acquisition of emotion and social behavior: highly anxious parents increase the risk of emotional (anxiety, depression) and…”
BackgroundFlandermeyer, E. M., & Sawin, K. G. (2019) · Digital Commons @ Butler University (Butler University) · Cited by 7 · see citing works
Büyüköksüz, E. (2024) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2024.100864 · Cited by 6 · see citing works
Xiao, Y., Liu, Y., Han, J., Li, Y., Zhang, L., Bai, L., Wang, X., Yin, Y., Wang, S., Tang, X., et al. (2022) · International Journal of Audiology · doi:10.1080/14992027.2022.2131637 · Cited by 6 · see citing works
“…cognitive fusion (i.e. the dominant control of thoughts in guiding actions) and experiential avoidance (i.e. rigidly avoiding, suppressing, or otherwise trying to control internal experiences) are two interrelated processes that produce psychological inflexibility (Simon and Verboon 2016).”
BackgroundKeulen, J., Deković, M., Vervoort, L., & Bodden, D. H. M. (2025) · Current Psychology · doi:10.1007/s12144-025-08328-3 · Cited by 4 · see citing works
“Psychological flexibility was measured using the Accep - tance and Fusion Questionnaire for Youth (AFQ-Y) (Greco et al., 2008 ; Simon & Verboon, 2016).”
Is Psychological Inflexibility a Predictor of Depression and Anxiety of Pre-Adolescents?
Kul, A., & Türk, F. (2024) · International Journal of Psychology and Educational Studies · doi:10.52380/ijpes.2024.11.3.1373 · Cited by 5 · see citing works
“Simon and Verboon (2016) found a positive and significant relationship between psychological inflexibility and anxiety levels in data from 267 children aged 8-10 years, suggesting that high levels of psychological inflexibility are associated with high levels of anxiety.”
BackgroundPsychometric Properties of the Dutch Child Avoidance Measure
Simon, E., Jong, H. J. B.-D., Butler, P., & Whiteside, S. P. H. (2023) · Child Psychiatry & Human Development · doi:10.1007/s10578-023-01517-w · Cited by 4 · see citing works
“The Dutch ver - sion of the AFQ-Y8 has good psychometric properties [ 34].”
MethodSelf-citationWearable Smart Emotion-Aware Gloves: Develops a New Way People Interact with Others
Shan, P., Luo, S., Shen, C., Cui, Z., Bian, Z., Lin, H., Zou, W., & Zhang, Y. (2019) · Advances in intelligent systems and computing · doi:10.1007/978-3-030-20476-1_15 · Cited by 4 · see citing works
Gómez, M. G., Bustamante, J. G., López-Ramos, V.-M., et al. (2019) · Preprints.org · doi:10.20944/preprints201910.0355.v1 · Cited by 3 · see citing works
“Although the AFQ-Y has been validated in various languages -Spanish [16], Italian [19], Swedish [20], or Dutch [9], we found some controversies concerning the factor structure of the measure.”
MethodResultInfluentialFukuya, Y., Miyamura, K., Funatogawa, T., Yamaguchi, T., Katagiri, N., & Nemoto, T. (2025) · Medicina · doi:10.3390/medicina61030445 · Cited by 2 · see citing works
“Another study showed a positive relationship between psychological inflexibility and anxiety among children [56].”
Keulen, J., Deković, M., Matthijssen, D., Schraven, J., & Bodden, D. H. M. (2025) · Behavior Therapy · doi:10.1016/j.beth.2025.10.004 · Cited by 4 · see citing works
Mendoza-Muñoz, M., López‐Gil, J. F., Pereira-Payo, D., & Pastor-Cisneros, R. (2025) · Children · doi:10.3390/children12081032 · Cited by 2 · see citing works
“Both constructs have been associated with a range of mental health problems, such as anxiety [9], depression [10], and trauma in adolescents.”
Apostolakis, M., Theodorou, M., Neophytou, K., & Panayiotou, G. (2022) · Frontiers in Psychology · doi:10.3389/fpsyg.2022.1002221 · Cited by 1 · see citing works
“Additional vulnerability factors, including Psychological Inflexibility are positively associated with SA or agoraphobia in samples of adults, children, and adolescents (Muris, 2002; McLaughlin et al., 2007; Levin et al., 2014; Tillfors et al., 2015; Simon and Verboon, 2016; Papachristou et al., 2018).”
BackgroundNavarrete, J., Brandolin, F., Lappalainen, P., García‐Rubio, C., Ferreira, C., Luciano, J. V., Lappalainen, R. I., & Kiuru, N. H. (2026) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2026.101015 · Cited by 1 · see citing works
Kaya, A., & ÖZOK, H. İ. (2025) · International Journal of Educational Studies and Policy · doi:10.63612/ijesp.1694359
Núñez, D., Trigueros, R., Yañez-Lizana, J., Aguilar-Parra, J. M., Salazar, J. M., Martínez, V., Gaete, J., & Langer, A. I. (2025) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2025.100933
- Authors
- Simon, E., & Verboon, P.
- Affiliations
- Open University of the Netherlands (NL)
- Corresponding author
- Simon, Ellin
- Venue
- Journal of Child and Family Studies
- Published
- 2016-08-31
- Volume
- 25
- Issue
- 12
- Pages
- 3565-3573
- ISSN
- 1062-1024 (ISSN-L)
- 1573-2843
- PMC
- PMC5104759
- OpenAlex
- W2517470131
- Semantic Scholar
- 54e61e4d0a1dcf3ba5861f5760688e5003ced115
- Cited by
- 39
- References
- 43
- Citations by year
- 2026: 2 · 2025: 6 · 2024: 5 · 2023: 5 · 2022: 4 · 2021: 2 · 2019: 7 · 2018: 5 · 2017: 2
- FWCI
- 6.15
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- cc-by
- Locations
- Journal of Child and Family Studies (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (submittedVersion)
- PubMed Central (submittedVersion)
- DSpace (Open University in the Netherlands) (submittedVersion, other-oa)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
- Social Sciences › Psychology › Clinical Psychology › Family and Disability Support Research
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Keywords
- psychological inflexibility, psychological flexibility, childhood anxiety, acceptance and commitment therapy, factor structure, construct validity, reliability statistics, middle-aged children
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