Advances in Neurodevelopmental Disorders

https://doi.org/10.1007/s41252-022-00259-5

ORIGINAL PAPER

Further Examination of the Children’s Psychological Flexibility

Questionnaire (CPFQ): Convergent Validity and Age Appropriateness
Chloe Lenoir1 · Jessica M. Hinman2 · Zhihui Yi2 · Mark R. Dixon2

Accepted: 1 May 2022

© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2022

Abstract
Objectives The present study examines the correspondence between the Children’s Psychological Flexibility Questionnaire
(CPFQ) and three commonly used psychological flexibility measures between a sample of neurotypical children and adults.
Methods One hundred and one children and 106 adults completed the CPFQ, Child and Adolescent Mindfulness Measure
(CAMM), Avoidance and Fusion Questionnaire-Youth (AFQ-Y), and the Acceptance and Action Questionnaire-II (AAQ-II),
and results were compared within and between age groups.
Results Correlations between scores on each measure were computed and yielded statistically significant correlations between
the CPFQ and the CAMM (r = .553, p < .001), the AFQ-Y (r = − .646, p < .001), and the AAQ-II (r = − .563, p < .001).
Conclusion The obtained measures of CPFQ suggest that the measure is appropriate for use with children and adult popula-
tions. The findings are consistent with patterns observed on established measures, establishing convergent validity among
investigated measures. Implications for the age appropriateness of the language used on CPFQ and the CPFQ’s clinical
utility are discussed.

Keywords Psychological flexibility · Mindfulness · Adults · Children

The psychological well-being of children and adolescents Moos, 1987). Experiencing adverse events, such as abuse,
is a growing concern as diagnostic rates for psychological bullying, and community or in-home violence, can put chil-
conditions (Merikangas et al., 2010). Prevalence rates of dren at a higher risk for psychological distress in childhood
childhood anxiety and depression have steadily increased and later in life (Kalmakis & Chandler, 2014).
throughout the last decade, and rates of anxiety and behav- Due to increased awareness regarding the importance of
ioral disorders are on the rise among adolescents (Bitsko childhood psychological well-being, researchers, educators,
et al., 2018; Merikangas et al., 2010). According to par- and psychologists have developed instruments to evaluate
ent-reported data, the prevalence of childhood anxiety and children’s and adolescents’ psychological states. Histori-
depression diagnoses rose from 5.4% in 2003 to 8.4% in cally, psychological assessments developed for children
2012 (Bitsko et al., 2018). The rise in psychological distress have focused on behavior, developmental milestones, intel-
is alarming as childhood and adolescence are critical stages ligence, cognition, and language, with few targeting overall
for social-emotional and psychological development. The psychological well-being (Cashel, 2002; Kamphaus et al.,
psychological well-being of children can impact a child’s 2000). Over time, assessment of psychological and social-
performance in school and ability to make friends. It can emotional well-being in children has become more com-
also have delayed, long-term effects such as continued sig- mon. The Children’s Depression Inventory (CDI; Kovacs,
nificant psychological distress into adulthood (Holahan & 2010), Millon Adolescent Clinical Inventory-II (MACI-II;
Millon et al., 2020), and Revised Children’s Manifest Anxi-
* Mark R. Dixon ety Scale (RCMAS-2; Reynolds & Richmond, 2008) are
[email protected] among the existing assessments. However, some of these
measures require a clinical interview or observation by a
1
School of Psychological and Behavioral Science, Southern psychologist. Although these assessments may provide diag-
Illinois University, Carbondale, IL, USA
nostic information, they may not be practical for monitoring
2
Department of Disability and Human Development, the psychological well-being of children over short periods
University of Illinois Chicago, Chicago, IL, USA

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(Cashel, 2002). More recently, self-report measures have Questionnaire (AAQ-II) is a seven-item questionnaire that
become adopted for assessing psychological well-being in assesses the inflexibility processes of avoidance, fusion,
children and can be used efficiently in clinical and non-clin- and lack of engagement in meaningful behavior change
ical settings. Validated self-report measures quickly became (Hayes et al., 2004). Because the AAQ-II was developed
popular in clinical settings because they are brief, easy to and intended for use with an adult population, the Avoidance
access, and can be administered by providers other than psy- and Fusion Questionnaire for Youth (AFQ-Y) was developed
chologists (Kamphaus et al., 2000). Many existing measures to resemble content in the AAQ-II using child-friendly lan-
were specific to a particular psychological condition and did guage (Greco et al., 2008). The AAQ-II and AFQ-Y have
not capture overall psychological well-being. Additionally, been translated into different languages (Muris et al., 2017;
despite the increase in psychological instruments available Pennato et al., 2013; Pinto-Gouveia et al., 2012; Valdivia-
for use with children and adolescents, children’s assess- Salas et al., 2017; Yavuz et al., 2016), used as dependent
ments for evaluating overall psychological states, such as measures in research studies (Bernal-Manrique et al., 2020;
resilience, were scarce (Beck et al., 1961; Cashel, 2002). Lappalainen et al., 2021; Livheim et al., 2020; Punna et al.,
Recently, there has been an increase in the various instru- 2021), and have been adapted for different populations and
ments that measure overall psychological well-being through conditions (Ong et al., 2019). Another measure specifically
flexibility and mindfulness. Psychological flexibility is designed for children and adolescents is the Child and Ado-
defined as the ability to be actively aware of the present lescent Mindfulness Measure (CAMM). Unlike the AAQ-
moment to engage in value-driven behaviors regardless of II and AFQ-Y, which assess psychological flexibility as a
uncomfortable or unpleasant thoughts, feelings, or situations whole, CAMM was developed to measure mindfulness and
(Hayes et al., 2011). The psychological flexibility model present moment awareness skills in children and adoles-
consists of six interrelated processes. Acceptance involves cents (Greco et al., 2011). Similar to the AAQ-II and the
a willingness to tolerate, rather than avoid, uncomfortable or AFQ-Y, the CAMM has also been validated among diverse
unpleasant thoughts, feelings, or situations to contact mean- populations (Kuby et al., 2015; Prenoveau et al., 2018) and
ingful and delayed consequences. Defusion aims to reduce translated into different languages (Guerra et al., 2019; Roux
the unworkable contextual control of language, resulting in et al., 2019; Saggino et al., 2017).
undesirable or nonadaptive behaviors. Self-as-context is the In addition to existing measures, the Children’s Psy-
process of becoming aware of the difference between one’s chological Flexibility Questionnaire (CPFQ) was recently
self and the thoughts and evaluations that person has about developed to measure psychological flexibility in chil-
themselves. Present moment awareness involves actively dren and adolescents (Dixon & Paliliunas, 2018). Using
attending to all stimuli, including thoughts, feelings, and easy-to-understand child-friendly language, the CPFQ
bodily sensations, within the current environment without presents items that correspond with each of the six psy-
changing or avoiding them. Values are defined as qualities chological flexibility processes. Thus, the CPFQ provides
that motivate an individual to engage in patterns of behav- a global measure of psychological flexibility and sub-scores
iors that result in meaningful and reinforcing consequences. for each of the six processes. The CPFQ also includes a
Finally, committed action is the pattern of behavior that is corresponding caregiver report that allows caregivers to
in service of one’s values. In assessing psychological flex- respond to questions about their child’s psychological flex-
ibility, measures can evaluate global psychological flex- ibility. Although the CPFQ is a newly developed measure
ibility (e.g., AAQ-II), focus on a portion of the processes of psychological flexibility, early research on the CPFQ
(e.g., AFQ-Y), or focus only on one of the processes (e.g., shows significant convergent validity between the CPFQ
CAMM). and AFQ-Y among children with autism (Bachmann
Most of the measures which evaluate psychological flex- et al., 2021). Using a clinical sample of 29 children from
ibility are brief self-report questionnaires (Hayes et al., a behavior-analytic clinic, Bachmann et al. (2021) evalu-
2004, 2011). Psychological inflexibility, the counterpart ated the correlation between CPFQ, AAQ-II, AFQ-Y, and
of flexibility, is thought to contribute to or cause various CAMM. The research team reported convergent validity
psychopathologies (Hayes et al., 2006). Recently, research between CPFQ and AFQ-Y (r = − 0.449, p = 0.015), as the
has demonstrated the clinical utility of using psychological- result showed a statistically significant negative correlation
flexibility measures as indices for evaluating overall psy- between CPFQ and AFQ-Y with a medium strength of asso-
chological well-being (Fledderus et al., 2010). Although ciation. Authors also reported divergent validity between
many different psychological flexibility measures provide CPFQ and the other two measures, as CPFQ’s correla-
a valuable method for assessing psychological well-being, tion between AAQ-II (r = − 0.324, p = 0.086) and CAMM
there are limited options for evaluating psychological flex- (r = 0.279, p = 0.143) failed to reach statistical significance
ibility among children. Arguably the most widely used psy- with low to medium strength of association. However,
chological flexibility measure, the Acceptance and Action Bachmann et al. (2021) included a relatively small sample

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size among clinical populations. The statistically insignifi- Table 1  Participant demographic information
cant correlation between CPFQ and the AAQ-II and the < 18 y/o > 18 y/o
CAMM could be attributed to potential type-II errors due to
the small sample size. Also, individuals with developmental N 101 106
disabilities often show deficits in language skills, and the Age
extent to which their under-developed language abilities 5–10 29
affect the result of the study was not clear. Although their 11–14 32
results to some degree speak to the age appropriateness of 15–17 40
the language used on CPFQ, further analysis is necessary 18–29 52
by directly comparing the obtained outcome from the CPFQ 30–39 14
with established measures across different age groups, espe- 40–49 10
cially among those also specifically designed for children. 50–59 22
Thus, the purpose of the current study was to extend 60–69 5
the prior study by Bachmann et al. (2021) and evaluate 70 + 3
the convergent validity between the CPFQ and established Gender
measures. A statistically significant convergent validity was Female 51 81
expected between the CPFQ and established measures (i.e., Male 39 23
AAQ-II, AFQ-Y, and CAMM) due to similarities in the Non-binary 4 0
construct measured. Specifically, we hypothesized a statis- Trans male 0 0
tically significantly positive correlation between the CPFQ Trans female 1 0
and CAMM, given that a higher score on each measure was Prefer not to answer 6 2
indicative of increased psychological flexibility, and present Race
moment awareness and mindfulness, respectively. We also Asian/Pacific Islander 2 1
hypothesized a statistically significantly negative correlation Black 23 52
between the CPFQ and both AFQ-Y and AAQ-II, given that Latinx 13 3
higher scores on the AFQ-Y and AAQ-II were indicative of Indian/Native 2 2
psychological inflexibility. The current study also aimed to White 29 45
indirectly evaluate the age appropriateness of the language Prefer not to say 32 3
used on CPFQ by comparing the obtained outcome across Diagnosis
age groups and comparing CPFQ’s age-score distribution ADD/ADHD 10 4
with other measures. Anxiety 12 22
ASD 0 1
Depression 13 28
Methods DD/ID 2 2
LD 5 1
Participants ODD 2 1
Other 0 3
The current study included 207 participants. The inclusion None 74 66
criteria for the current study required that participants be
at least 5 years old due to the readability of the question-
naires. Thus, researchers recruited participants ages 5 to 17 hyperactivity disorder (ADHD), 12 reported anxiety, 13
(n = 101) and 18 to 90 (n = 106). Participants’ demographic reported depression, two reported developmental/intellectual
information is provided in Table 1. disability, five reported a learning disability, two reported
The average age of participants in the child group was oppositional defiance disorder (ODD), and 74 reported no
13.13 years (range 7–17), and the median age of participants diagnosis. All but 6 participants in the child group were
was 14 years. Of the participants included in the child group, adolescents (i.e., aged 10 or above).
51 identified as female, 39 as male, four identified as non- The average age of participants in the adult group was
binary, one identified as trans female, and six preferred not 36.36 years (range, 18–70), and the median age of par-
to answer. Twenty-nine participants were white, 23 were ticipants was 30 years. Of the participants included in the
black, 13 were Latinx, two were Asian and pacific island- adult group, 81 identified as female, 23 as male, and two
ers, two were Indian/native, and 32 did not report their race. preferred not to answer. Fifty-two participants were black,
Participants also self-reported diagnoses. Ten participants 45 were white, three were Latinx, two were Indian/native,
reported attention-deficit disorder (ADD)/attention-deficit one was Asian and pacific islander, and three did not report

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their race. In addition, four participants had ADD/ADHD, using a visual scale. At the top of the questionnaire, five pro-
22 reported anxiety, 28 reported depression, two reported a gressively shaded circles correspond to the CPFQ’s Likert
developmental/intellectual disability, one reported a learn- scale, with an empty circle indicating never (0) and a fully
ing disability, one reported ODD, and one reported ASD. shaded circle indicating always (4).
Additionally, three reported having a diagnosis other than On the backside of the questionnaire are instructions for
the options provided, and 74 reported having no diagnosis. scoring the CPFQ and a scoring grid. The scoring grid con-
sists of six sections, each representing one of the psychologi-
Procedures cal flexibility processes and containing the CPFQ item num-
bers corresponding to that process. Clinicians are instructed to
Before beginning the study, the researchers analyzed the transfer the child’s responses on each item to the correspond-
measures being administered to determine the readability ing item number and reverse score specific item numbers (i.e.,
level of each measure. Results of the analysis indicated that changing 0 to 4, 1 to 3, 3 to 1, 4 to 0). Altogether, twelve of the
children could understand the four measures being used items are reversed scored. Clinicians are instructed to calcu-
as young as 5 years. All participants were recruited online late the core process subtotal by summing the four questions
via social media and personal contacts of the researchers which target each process. Clinicians then calculate the total
and completed the surveys anonymously online via Google psychological flexibility score by summing all of the items.
Forms. Potential participants were asked to provide consent Scores can range from 0 to 96, with higher scores indicating
for themselves or assent for their children before accessing greater psychological flexibility and lower scores indicating
the online surveys. All participants were asked to provide greater psychological inflexibility. Layout of the CPFQ was
basic demographic information before presenting the four adapted so it can be administered online.
psychological flexibility questionnaires if they provided con-
sent. Altogether, participants responded to 58 survey items Child and Adolescent Mindfulness Measure (Greco et al.,
which took approximately 45 min for each person to com- 2011)
plete. Participants were informed that they could skip items
if they felt uncomfortable responding to the item or did not The CAMM is a 10-item self-report measure of mindfulness
know how to respond to it. in children and adolescents. This measure primarily focuses
on aspects of mindfulness and presents relatable and age-
Measures appropriate items for most children and adolescents. Exam-
ples of items on the CAMM include “I tell myself that I
Children’s Psychological Flexibility Questionnaire: Child shouldn’t feel the way I’m feeling,” “I get upset with myself
Report (Dixon & Paliliunas, 2018) for having certain thoughts,” and “I stop myself from having
feelings that I don’t like.” Participants are asked to respond
The CPFQ is a 24-item psychological flexibility measure to each item using a 5-point Likert scale to indicate how
that presents questionnaire items using accessible and child- often each item is true for them by selecting never true (0),
friendly language. This measure assesses overall psycho- rarely true (1), sometimes true (2), often true (3), and always
logical flexibility and also isolates each of the six different true (4). Clinicians are instructed to reverse score all ten
processes. Throughout the questionnaire, participants are items and sum those scores (i.e., changing 0 to 4, 1 to 3, 3
presented with different scenarios which target acceptance, to 1, and 4 to 0). Scores can range from 0 to 40, with higher
defusion, present moment awareness, self-as-context, val- scores indicating greater levels of mindfulness.
ues, and committed action. Examples of items on the CPFQ
which correspond which the six processes include “It’s OK Avoidance and Fusion Questionnaire‑Youth (Greco et al.,
to be scared,” “My thoughts don’t make me do what I do,” 2008)
“I notice when my body feels different,” “If I did some-
thing wrong, that doesn’t make me bad,” “There are things The AFQ-Y is a 17-item self-report measure of psychologi-
that I really care about,” and “I try really hard every day,” cal inflexibility in children and adolescents. This measure
respectively. presents items describing aspects of psychological inflex-
Each of the six processes corresponds with four items on ibility, precisely the experiential avoidance, and cognitive
the questionnaire, two of which are reverse scored. Partici- fusion processes. Examples of items on the AFQ-Y include
pants are asked to respond to each item on the questionnaire “My life won’t be good until I feel happy,” “I can’t stand
using a 5-point Likert scale and indicate how much they feel to feel pain or hurt in my body,” and “I do worse in school
that way by selecting: never (0), rarely (1), sometimes (2), when I have thoughts that make me feel sad.” Participants
often (3), or always (4). The CPFQ also allows clinicians are asked to respond to each item using a 5-point Likert scale
to read the questionnaire items to participants and respond to indicate how true each sentence is for them by selecting

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not at all true (0), a little true (1), pretty true (2), true (3), the current study, only 197 participants completed all four
and very true (4). When scoring the AFQ-Y, clinicians are measures. Thus, participants who did not complete all four
instructed to sum the scores of all the items. Scores can measures were excluded for analysis pairwise. For example,
range from 0 to 68, with higher scores indicating greater if the participant only completed the CPFQ, AAQ-II, and
levels of avoidance and fusion. CAMM, but not AFQ-Y, he will be included in the analy-
sis involving CPFQ, AAQ-II, and CAMM, but will not be
Acceptance and Action Questionnaire‑II (Bond et al., included in analysis involving AFQ-Y.
2011)
Convergent Validity
The AAQ-II is a 7-item self-report measure of psychological
inflexibility related to experiential avoidance. Examples of Statically significantly positive correlations were observed
items on the AAQ-II include “I’m afraid of my feelings,” between the CPFQ and the CAMM (r = 0.553, p < 0.001)
“Emotions cause problems in my life,” and “Worries get in with a large strength of association. Statistically signifi-
the way of my success.” Participants are asked to respond to cantly negative correlations were also observed between
items using a 7-point Likert scale indicating how true each the CPFQ and the AFQ-Y (r = − 0.646, p < 0.001), and the
statement is by selecting never true (1), very seldom true AAQ-II (r = − 0.563, p < 0.001), both with a large strength
(2), seldom true (3), sometimes true (4), frequently true (5), of association. A secondary analysis was conducted to
almost always true (6), and always true (7). Clinicians are evaluate the correlation among obtained measures within
instructed to sum the scores of the seven items to obtain a each age group. Statistically significantly negative correla-
score for the AAQ-II. Scores can range from 7 to 49, with tions were observed between the CPFQ and the AFQ-Y (r =
higher scores indicating greater levels of psychological − 0.497, p < 0.001), and the AAQ-II (r = − 0.450, p < 0.001)
inflexibility. for participants under the age of 18 years with medium
strength of association. The correlation between CPFQ
Data Analyses and CAMM was not statistically significant (r = − 0.077,
p = 0.446) with a small strength of association. Responses
We evaluated the convergent validity between the CPFQ, from participants over the age of 18 also yielded statisti-
CAMM, AFQ-Y, and AAQ-II across participants of all ages, cally significantly negative correlations between the CPFQ
the convergent validity within the child and adult groups, and the AFQ-Y (r = − 0.602, p < 0.001), and the AAQ-II
and the age appropriateness of the CPFQ. The Pearson cor- (r = − 0.486, p < 0.001), and a statistically significantly
relation coefficient was calculated to determine the agree- positive correlation between CPFQ and CAMM (r = 0.596,
ment between the CPFQ and the three other measures to p < 0.001), all with medium to large strength of associa-
evaluate convergent validity. A series of visual analyses were tion. Additional analyses were conducted to compare the
conducted to evaluate the age appropriateness of the CPFQ. obtained degree of association between participants under
For all statistical analyses, the alpha level was set at 0.05. and above 18 years old. Results showed that the correlation
between CPFQ and CAMM was significantly different in
the two groups (z = 5.31, p < 0.001). No statistically sig-
Results nificant difference existed in AFQ-Y (z = 1.04, p = 0.15) and
AAQ-II (z = 0.32, p = 0.37).
Two hundred and six participants completed measures evalu-
ated in the current study. As seen on Table 2, participant CPFQ Age Distribution
scores on the CPFQ ranged from 33 to 76. Scores on the
CAMM ranged from 2 to 40. On the AFQ-Y, scores ranged A box and whisker plot was generated to identify CPFQ’s
from 2 to 56, and on the AAQ-II, participants’ scores ranged age-score distribution pattern. As depicted in Fig. 1, scores
from 7 to 47. Although 206 participants were involved in on the CPFQ were similar across participants of the different
age groups, indicating that the score on CPFQ was largely
independent of the participant's age. A bell curve was super-
Table 2  Descriptive statistics for obtained measures imposed on top of the frequency distribution of obtained
Measure N M SD Range outcome on each measure to compare the distribution pat-
tern of CPFQ’s score with other measures and broken down
CPFQ 199 56.28 8.67 33–76
by participants below or above 18 years old. As shown in
CAMM 206 18.85 6.74 2–40
Fig. 2, the pattern of distribution of CPFQ was similar to that
AFQ-Y 203 25.99 11.44 2–56
of CAMM, AAQ-II, and AFQ-Y, providing additional evi-
AAQ-II 206 22.32 8.94 7–47
dence for its convergent validity. Moreover, the results from

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80 CPFQ suggested that participants below 18 years old dem-

onstrated a higher level of psychological inflexibility, which
was verified by the observed pattern of CAMM, AAQ-II,
60 and AFQ-Y. A further independent sample t-test showed a
CPFQ Score

statistically significant difference in CPFQ score between the

two age groups (t = 9.18, d = 1.30, p < 0.001). As shown on
40 Fig. 3, similar outcome was obtained on CAMM (t = 10.14,
d = 1.39, p < 0.001), AFQ-Y (t = 6.34, d = 0.89, p < 0.001),
and AAQ-II (t = 5.42, d = 0.76, p < 0.001).
20

0 Discussion

The purpose of conducting the current study was twofold.

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First, we aimed to extend upon the findings of Bachmann
et al. (2021) and evaluate the convergent validity between
the CPFQ and the CAMM, AFQ-Y, and AAQ-II in a non-
50

Age Group clinical sample of children and adults. Second, we sought

to evaluate the age appropriateness of the CPFQ by com-
paring the pattern of scores across age groups. By con-
Fig. 1  Median, standard deviation, and range across age groups on
the CPFQ ducting the study with a non-clinical sample, we expected
to observe correlations between the CPFQ and the other
psychological flexibility measures and find that the results

Distribution of CPFQ Score Distribution of CAMM Score

Under 18 Under 18
Above 18 Above 18

0 16 32 48 64 80 96 0 10 20 30 40 50
CPFQ Score CAMM Score

Distribution of AAQ-II Score Distribution of AFQ-Y Score

Under 18 Under 18
Above 18 Above 18

7 14 21 28 35 42 49 0 16 32 48 64
AAQ-II Score AFQ-Y Score

Fig. 2  Distribution graph of CPFQ, CAMM, AFQ-Y, and AAQ-II

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Fig. 3  Comparison of CPFQ, 96 40

t = 9.18 t = 10.14
CAMM, AFQ-Y, and AAQ-II 35
80 p < .001 p < .001
scores between age groups
30

CAMM Score
CPFQ Score
64
25
48 20
32 15
10
16
5
0 0
Under 18 Above 18 Under 18 Above 18

68 49
t = 6.34 t = 5.42
p < .001 42 p < .001
51 35

AAQ-II Score
AFQ-Y Score

28
34
21

17 14
7
0 0
Under 18 Above 18 Under 18 Above 18

obtained on the CPFQ were independent of age. Although measures can also be used to evaluate participants’ compre-
our findings differ from those obtained by Bachmann et al. hension of CPFQ’s items.
(2021), the current study provides further evidence sup- Another interesting finding was the difference in the
porting the convergent validity between the CPFQ and the strength of association between CPFQ and CAMM among
AFQ-Y among children. It provides preliminary evidence participants above and below 18 years old (p < 0.001). Such
supporting the convergent validity between the CPFQ, difference was not present between the other two measures
CAMM, and AAQ-II in a non-clinical sample. Our find- (CPFQ and AFQ-Y, p = 0.15; CPFQ and AAQ-II, p = 0.37)
ings likely differ from those of Bachmann et al. (2021) and the reason for this was likely due to the fact that the
due to the clinical sample employed by Bachmann and correlation between CPFQ and CAMM failed to reach
colleagues. statistical significance among participants under 18 years
Furthermore, the current finding provides preliminary old but showed a significantly positive correlation among
evidence that CPFQ scores are independent of age, as par- participants above 18 years old. Given the overwhelming
ticipants’ scores on CPFQ did not increase or decrease with convergent validity between CPFQ and other measures and
age. The observed differences in psychological flexibility consistent findings across age groups, it is likely that the
between participants above and below 18 years old, as observed phenomenon was caused by participants below
reported on CAMM, AFQ-Y, and AAQ-II, were consistent 18 years old responding to CPFQ and CAMM differently. It
with the distribution pattern reported on CPFQ, indicating is possible that participants in different age groups respond
CPFQ’s sensitivity to capture this difference between age to the language used in either CPFQ or CAMM differently,
groups. Together, the convergent validity and the age-score or that the sensitivity of CPFQ and CAMM is different
distribution support the age appropriateness of the language across age groups. It is also possible that such difference is
used on CPFQ. It can reliably produce outcome measures caused by the variation in each of the instrument’s construct,
that are independent of age and are verified by other meas- since CAMM only measures a subset of components concep-
ures. However, it should be further pointed out that the tualized in the psychological flexibility model while CPFQ
current method only indirectly measured the age appropri- measures all its components. Nevertheless, future research
ateness of the CPFQ, as it relied on visual analysis and con- might look into this difference and evaluate whether such
firmatory findings from other established measures. Future observation can be replicated, and if so, the reason behind it.
research can use statistical methods such as item response Overall, the obtained results extend findings by Bach-
theory to provide a more direct appraisal of participants’ mann et al. (2021) and demonstrate satisfactory conver-
responses across age group (Hays et al., 2000). Self-reported gent validity between the CPFQ and existing psychological

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flexibility measures among a larger non-clinical sample. but not least, although the correlation analysis reached sta-
It also provides preliminary evidence supporting CPFQ’s tistical significance, the strength of association between the
age appropriateness in terms of its format and language. CPFQ and other measures varied from moderate to large,
Because of this, CPFQ may offer unique benefits in clini- indicating potential misalignment of the constructs they
cal settings, especially when the intended audiences have claim to measure. This question could be answered by con-
deficits in language and communication skills. Besides that, ducting factor analysis simultaneously using the CPFQ and
CPFQ remains the only self-report psychological flexibility existing psychological flexibility measures and examining
measure to date that is specifically designed for children whether different factors (i.e., processes of the psychologi-
that allows both a global index of flexibility and indexes cal flexibility model) converge.
for each of the six processes. It may provide more compre- Future studies should continue to evaluate the psycho-
hensive clinical utility as the clinician can separate the six metric properties and clinical utility of the CPFQ. While
psychological flexibility processes and tailor intervention to the current study demonstrates satisfactory convergent
focus more on processes demonstrating greater inflexibility. validity between the CPFQ and other commonly used psy-
At the same time, the CPFQ is tightly integrated with the chological flexibility measures, the psychometric proper-
AIM curriculum (Dixon & Paliliunas, 2018). As a behavior- ties of the CPFQ can be further examined by evaluating
analytic curriculum that uses language-based approaches to internal consistency, test–retest reliability, and conduct-
promote social-emotional development, the AIM curriculum ing factor analyses. Additionally, it would be valuable
provides many ways the clinician can use CPFQ to pinpoint for future studies to utilize the CPFQ within clinical and
specific programs for intervention. Overall, the current study applied settings and among diverse clinical samples. Since
aligns with existing evidence supporting CPFQ as a valid the CPFQ derives directly from the psychological flexibil-
measure for psychological flexibility among children and ity model, it would be valuable for future research to use
adolescents. CPFQ seems to use age-appropriate language the CPFQ as a measure of flexibility among children who
and may offer unique clinical benefits when compared to are learning to practice ACT and mindfulness. Lastly, to
existing measures. further examine the relationship between psychological
and behavioral flexibility, future studies can utilize the
Limitations and Future Directions CPFQ and behavioral measures together to evaluate ACT’s
efficacy in increasing flexibility.
Although the obtained outcome is promising, there are
some limitations to the current study. Because all partici-
pants were recruited online and participated anonymously, Author Contribution CL: conducted research, recruited participants,
and helped analyze the data. JMH: helped develop the methods of the
we could not verify the demographic and diagnostic infor- study, analyzed the data, and wrote parts of the paper. ZY: conducted
mation provided by participants. Participants were also data analysis and wrote parts of the paper. MRD: developed the meth-
not asked about familiarity with ACT, AIM, mindfulness, ods of the study and collaborated in the writing and editing of the final
or any of the measures in the past. Thus, future research manuscript.
should continue to evaluate the CPFQ in clinical and non-
Data Availability The data that support the findings of this study are
clinical populations, including those who have experience available from the second author, JMH ([email protected]), upon rea-
with ACT or other behavioral therapies and those who do sonable request.
not. Another limitation related to the anonymity of par-
ticipants is that we are uncertain whether or how much Declarations
parents helped or prompted their children to complete the
surveys. To recruit participants under the age of 18, we Ethics Approval All procedures performed in studies involving human
posted the survey link to social media sites, emailed the participants were in accordance with the ethical standards of the institu-
tional research committee and with the 1964 Helsinki Declaration and
link to personal contacts, and asked that parents’ consent to its later amendments or comparable ethical standards. Research was
their children participating. We did not provide any instruc- conducted when all authors were afflicted with Southern Illinois Uni-
tions to the parents asking them not to help or prompt their versity. The Human Subject Committee approved the study at Southern
children, and it is possible that some parents provided more Illinois University (Protocol number 19266).
assistance to their children than others. Future studies Informed Consent Consent was obtained for all participants. Assent
should consider administering the surveys to participants in was obtained by the parents of all participants under the age of 18.
person rather than virtually to increase the validity and reli-
ability of these findings. Like the procedures used in Bach- Conflict of Interest Mark R. Dixon receives small royalties from the
mann et al. (2021), participants were asked to complete the book that the CPFQ originally published. The CPFQ in its entirety
self-report measures in succession, which means they could is available free online at https://​www.​accep​tiden​tifym​ove.​com. The
remaining authors declare no competing interests.
have become fatigued completing them consecutively. Last

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Advances in Neurodevelopmental Disorders

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