Psychological Flexibility as a Moderator of the Association Between Premenstrual Dysphoric Disorder, Depression, Anxiety, Positive Parenting, and Negative Parenting: A Cross-Sectional Study

doi:10.21203/rs.3.rs-5398703/v1

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Research Article

Psychological Flexibility as a Moderator of the Association Between Premenstrual Dysphoric Disorder, Depression, Anxiety, Positive Parenting, and Negative Parenting: A Cross-Sectional Study

https://doi.org/10.21203/rs.3.rs-5398703/v1

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published 07 Apr, 2025

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Background

This study investigated whether psychological flexibility moderates the relationship between premenstrual dysphoric disorder (PMDD) symptoms and depression, anxiety, positive parenting, and negative parenting.

Methods

A sample of 1,538 menstruating mothers with children aged 0 to 3 years (227 with 0-year-olds, 428 with 1-year-olds, 409 with 2-year-olds, and 424 with 3-year-olds) was assessed utilizing the Premenstrual Dysphoric Disorder Scale (PMDDS), Parental Acceptance and Action Questionnaire (PAAQ), and Hospital Anxiety and Depression Scale (HADS).

Results

The interaction effects between PMDDS and PAAQ scores were significantly associated with anxiety and positive parenting, after controlling for other variables. Notably, higher PAAQ scores were associated with increased positive parenting, even in the presence of worsened PMDD symptoms. Furthermore, psychological flexibility, as measured by the PAAQ, had an independent effect on both depression and anxiety, though no moderating effect was observed.

Conclusions

Interventions aimed at enhancing psychological flexibility may be beneficial for mothers with premenstrual dysphoric disorder who are raising infants and toddlers.

acceptance and commitment therapy

psychological flexibility

negative parenting

positive parenting

premenstrual dysphoric disorder (PMDD)

depression

anxiety

mothers

toddler development

In Japan, in 2022, the birth rate was projected to fall below 800,000 for the first time, exhibiting an accelerating decline, while the number of child abuse cases was expected to increase by 105.5% compared to the prior year, equating to an additional 11,510 cases reported annually [1]. A prior study indicated that 8.9% of mothers fell into the abusive category, while 30.4% were classified as sub-abusive [2]. These statistics suggest a significant number of mothers are at risk of engaging in abusive behaviors, thus jeopardizing their child-rearing situations.

Dalton [3] highlighted clinical findings indicating that premenstrual syndrome (PMS) often develops and worsens after childbirth. PMS is characterized by various mental and physical symptoms, including irritability, depressive mood, fatigue, mood swings, and anxiety. Premenstrual dysphoric disorder (PMDD), a severe form of PMS, presents with more pronounced psychological symptoms, such as mood instability, increased irritability, and heightened nervousness. The prevalence of PMS among women is approximately 18–21% [4, 5], while that of PMDD ranges from 3–8% [6–8]. Among Japanese women in their 20s to 40s, those who have given birth report significantly more psychological symptoms, such as irritability and depression, compared to physical symptoms [9]. Furthermore, these findings suggest a potential association between PMS and PMDD symptoms and problematic emotional interactions with children [10].

Recently, Acceptance and Commitment Therapy (ACT), which aims to enhance psychological flexibility, has demonstrated effectiveness in improving emotion regulation and fostering positive parent-child relationships. While ACT is part of traditional Cognitive Behavioral Therapy (CBT), it specifically focuses on the functions and contexts of psychological phenomena rather than the content of thoughts, feelings, and sensations. ACT comprises six core therapeutic processes: "contacting the present moment," "defusion," "acceptance," "self-as-context," "values," and "committed action," as established by Hayes et al. [11]. A systematic review of ACT’s effectiveness in supporting various groups of parents, including those raising children with chronic pain, revealed improvements in parent-reported symptoms of their children's physical or psychological functioning, as well as reductions in parent-reported measures of stress, depression, and anxiety [12–19].

Research indicates that parents with low psychological flexibility are more likely to employ ineffective parenting practices, such as harsh discipline and inconsistent rules [20, 21]. Conversely, higher psychological flexibility is associated with numerous positive outcomes, including enhanced quality of life, greater emotional well-being, and improved psychological functioning [22, 23]. By contrast, low psychological flexibility correlates with increased emotional reactivity [24] and heightened psychopathology [25].

These findings suggest that PMDD symptoms may adversely affect mothers' depression, anxiety, and nurturing behaviors. Additionally, low psychological flexibility is strongly linked to affective disorders [26–31], and improvements in psychological flexibility have been reported to correlate with better outcomes in these disorders [32]. Therefore, psychological flexibility may moderate the relationship between PMDD symptoms and depression, anxiety, and nurturing behaviors in mothers (Fig. 1). We hypothesize that the psychological flexibility of mothers raising children aged 0–3 years may mitigate the association between maternal PMS/PMDD symptoms and negative parenting behaviors, depression, and anxiety symptoms. If psychological flexibility is shown to alleviate PMS/PMDD symptoms and reduce negative parenting behaviors, along with depressive and anxiety symptoms, this would highlight the utility of ACT interventions in supporting parents and clarify how to expand and adapt these interventions.

Poor psychological flexibility is associated with various forms of psychopathology and related issues in cross-sectional studies [26, 27], including depression [31], post-traumatic stress [28], and substance abuse [29, 30]. Longitudinal studies suggest that psychological inflexibility plays a role in the development of mood and anxiety disorders [31]. Many treatment studies utilizing the ACT for mood and anxiety disorders report that psychological flexibility mediates, at least partially, the outcomes [32]. However, research on the relationship between psychological flexibility and PMDD or PMS is lacking.

Based on these findings, PMDD is believed to impact depression, anxiety, and parenting behavior. Although the relationship between PMDD and psychological flexibility remains unclear, we hypothesize that psychological flexibility may moderate the effects of PMDD on depression, anxiety, and parenting behavior (see Fig. 1). In summary, we propose that a mother’s psychological flexibility in raising a child aged 0–3 years could weaken the association between her PMS/PMDD symptoms and negative parenting behaviors, as well as depressive and anxiety symptoms. Should it be established that psychological flexibility reduces PMS/PMDD symptoms and negative parenting behaviors (as well as depressive and anxiety symptoms) in mothers raising children aged 0–3 years, the efficacy of ACT interventions in supporting parents will be substantiated, and the scope for adaptation will become clearer.

2.1. Participants

Data for this secondary analysis were collected as part of the research on the standardization of the Japanese version of the Parental Acceptance and Action Questionnaire (PAAQ-J) [33]. The data analyzed in this study were collected in December 2020. Participants were recruited by Rakuten Research, Inc., an online marketing research company with access to approximately 2.3 million Japanese survey respondents. An e-mail containing a link to an online questionnaire was sent to randomly selected individuals stratified by sex and age across Japan.

The sample comprised 2,000 mothers raising children aged 0 to 3 years (mean age of children: 1.57 ± 0.74 years; mean age of mothers: 33.58 ± 4.7 years), with 500 children in each age category (0, 1, 2, and 3 years). The inclusion criterion required participants to be mothers of children aged between 0 and 3 years, with no exclusion criteria applied. If a mother had more than one child within the specified age range, she was asked to select one child for the survey.

2.2. Measures

2.2.1 Demographic information

The mothers were asked to provide demographic information, including their age, current medical history (mental disorders, physical diseases, PMS, and PMDD), ongoing medications, menstruation details (including premenstrual, menstrual, and postmenstrual phases), menstrual cycle characteristics, menstrual stability, employment status, and number of births. Additionally, information about the children was collected, including the number of children, eligible children's ages, and the presence or absence of disabilities.

2.2.2 Japanese version of the Parent Acceptance and Action Questionnaire (PAAQ-J [32])

The Parental Acceptance and Action Questionnaire (PAAQ) is a scale developed by Cheron et al. [34] to assess caregivers' psychological flexibility regarding experiential avoidance. The Japanese version of the PAAQ (PAAQ-J) was developed by Okajima and Okajima [32], with confirmed reliability and validity. The PAAQ-J is a self-administered 7-point (1 = Never True to 7 = Always True) comprising 12 items across three factors: inaction behavior, inaction perception, and unwillingness (Cronbach’s α = 0.80 for the total scale; α = 0.84, 0.72, and 0.68 for each factor, respectively). Test-retest reliability showed an intraclass correlation coefficient of 0.49 (95% CI: 0.44–0.54). Higher scores on the PAAQ-J indicate greater psychological inflexibility.

2.2.3 Hospital Anxiety and Depression Scale (HADS [34]).

The HADS is a 14-item scale assessing anxiety and depressive symptoms, comprising seven items for anxiety (HADS-A) and seven for depression (HADS-D). Participants respond to each symptom on a 4-point scale (1–4), with higher scores indicating more severe symptoms. The Japanese version of the HADS was developed by Hatta et al. [36], with Cronbach's α reported as 0.80 for HADS-A, and between 0.59 and 0.61 for HADS-D. Higher HADS scores reflect greater levels of depression and anxiety.

2.2.4 Premenstrual Dysphoric Disorder Scale (PMDDS; Miyaoka et al. [37])

The PMDDS is a 17-item scale measuring symptoms of premenstrual dysphoric disorder (PMDD) and includes a 4-item self-report questionnaire (1 = Not at all to 4 = Very much), with higher scores indicating more severe PMDD symptoms. The scale encompasses six items related to fatigue and/or physical symptoms, seven items for depressive moods, and four items for dysfunctional relationships and/or anger. An individual is suspected of PMDD when they endorse at least one item with a score of 4 (Very much) and at least four items with a score of 3 (Quite a lot) or 4 (Very much). Cronbach's alpha coefficients were α = 0.85 for fatigue and/or physical symptoms, α = 0.84 for depressive moods, α = 0.84 for dysfunctional relationships and/or anger, and α = 0.77 for the total PMDDS.

2.2.5 Questionnaire on Dealing with Children (QDC; Shimada, Kayashima, & Suzuki [10])

The QDC is an 8-item scale that assesses children's coping behavior and comprises two factors: five items related to negative parenting and three items related to positive parenting. The scale is administered utilizing a 4-point scale (1 = Not at all to 4 = Very much). Cronbach's α coefficients were α = 0.79 for negative parenting, α = 0.71 for positive parenting, and α = 0.81 for the total QDC.

2.3. Procedures

This study was approved by the Research Ethics Committees of the University of Tokyo Health Sciences (17-27H) and Rikkyo University (21–31).

2.4. Data analysis

First, correlation analysis was conducted to examine the relationships among the scales. Correlation coefficients were interpreted based on Cohen’s criteria [38], with r = 0.1 indicating a small effect, r = 0.3 a moderate effect; and r = 0.5 a large effect. Second, a hierarchical multiple regression analysis was performed to assess the moderating effect of the PAAQ on the relationships between PMDDS and HADS-A, HADS-D, positive parenting, and negative parenting. In this analysis, PMDD served as the independent variable, while HADS-A, HADS-D, positive parenting, and negative parenting were the dependent variables. The PAAQ was included as a moderating variable, and demographic data were controlled. Interaction terms were created using centered variables and subsequently added to the model. If the interaction effect was significant, a simple slope test was conducted to elucidate the nature of the moderation effect. Statistical analyses were conducted using SPSS Statistics version 27 (IBM Corp., Armonk, NY, USA) and R statistical software version 4.4.0 (R Project for Statistical Computing, Vienna, Austria).

3.1 Demographic data

The analysis included 1,538 menstruating mothers (two-hundred and twenty-seven 0-year-olds, four-hundred and twenty-eight 1-year-olds, four-hundred and nine 2-year-olds, and four-hundred and twenty-four 3-year-olds) out of an initial sample of 2,000. Parent and child demographic data, including the number of children, employment status, birth order, and child age, are summarized in Table 1. To examine differences in scale scores (PAAQ, HADS-D, HADS-A, negative parenting, and positive parenting) based on parent and child attributes (number of children, employment status, birth order, and child age), a one-way ANOVA was conducted. Where significant differences were identified, scale scores were subjected to multiple comparisons using Bonferroni correction. For negative and positive parenting, we focused on parents with children aged 1 to 3 years, as the questionnaire items did not apply to children aged 0. The results indicated no significant differences in HADS-D, HADS-A, or PMDD scores based on parent or child attributes. Differences in PAAQ, negative parenting, and positive parenting scores related to these attributes are presented in Table 1.

3.2. Correlation coefficients among each scale

Correlation analysis revealed significant correlations among all scales (Table 2). PMDD was positively and moderately correlated with PAAQ (r = .31), HADS-D (r = .30), HADS-A (r = .54), and negative parenting (r = 0.34). Additionally, PAAQ scores exhibited a positive and moderate correlation with negative parenting (r = 0.44).

3.3. Moderation Analysis

Hierarchical multiple regression analysis was conducted to investigate the moderating effect of PAAQ on the relationship between PMDD and HADS-A, HADS-D, negative parenting, and positive parenting. In the analysis, PMDD served as the independent variable, while HADS-A, HADS-D, negative parenting, and positive parenting were treated as dependent variables. PAAQ acted as the moderating variable, with demographic data (number of children, employment status, birth order, and child age) controlled for in the analysis. Interaction terms were created using centrally processed variables and subsequently included in the model.

The results from the hierarchical multiple regression analysis (Table 3, Table 4) indicated that for HADS-D, the R² at step 3 was significant (R² = .102, F = 34.838, p < .001); however the change in R² (ΔR²) was not significant, suggesting the interaction term did not contribute additional explanatory power. For the HADS-A, R² at step 3 was significant (R² = .311, F = 138.476, p < .001) and the ΔR² was also significant (ΔR² = .004, p < .01). In the case of positive parenting, the R² at step 3 was significant (R² = .023, F = 6.011, p < .001) and the ΔR² was also significant (ΔR² = .008, p < .001). The interaction term between PMDD and PAAQ revealed a significant standardized partial regression coefficient (β = .498, p < .001). Conversely, for negative parenting, the R² at Step 3 was significant (F = 78.593, p < .001), but the ΔR² was not significant.

Given the significant standardized partial regression coefficients for the interaction between PMDD and PAAQ in relation to HADS-A, a simple slope analysis was performed (Fig. 2). This analysis illustrated the regression of PMDD on HADS-A at each respective value of PAAQ, utilizing + 1SD and − 1SD as reference points. The findings indicated that lower PMDD scores were associated with lower HADS-A, while higher PMDD correlated with higher HADS-A for both good PAAQ (-1SD) and poor PAAQ (+ 1SD) (simple slope = 0.16, p < .001; simple slope = 0.20, p < .001). Furthermore, lower PMDD was linked to lower HADS-A scores when PAAQ was better; similarly, even in cases of high PMDD, HADS-A scores were lower with better PAAQ (simple slope = 0.04, p < .01; Simple slope = 0.10, p < 001).

Since positive parenting also demonstrated significant standardized partial regression coefficients for the interaction, a simple slope analysis was conducted (Fig. 3). This analysis illustrated the regression of PMDD on positive parenting at each respective value of PAAQ, again using + 1 SD and − 1 SD as the standard. Further, lower PMDD was associated with higher positive parenting when PAAQ was good (-1 SD) (simple slope = 0.02, p < 05). Conversely, for poorer PAAQ (+ 1SD), lower PMDD was related to higher positive parenting, while higher PMDD was also linked to higher positive parenting (simple slope=-0.03, p < 001). For low PMDD, there was no significant difference in positive parenting between good and poor PAAQ; however, for high PMDD, good PAAQ was associated with high positive parenting while poor PAAQ correlated with low positive parenting (simple slope = 0.01, n.s.; simple slope=-0.05, p < 001).

This study aimed to determine whether psychological flexibility acts as a moderating variable in the effects of PMDD symptoms on negative parenting, positive parenting, depressive symptoms, and anxiety symptoms in mothers of children aged 0–3 years. Results indicated that psychological flexibility moderated the impact of PMDD symptoms, particularly on anxiety and positive parenting.

From the initial sample of 2,000 mothers raising children between the ages of 0 and 3 years, the analysis focused on 1,538 menstruating mothers. For the analysis of negative and positive parenting behaviors, we further narrowed the sample to 1,261 parents of children aged 1–3 years, as the item content related to parenting did not apply to 0-year-old children. We examined the differences in scale scores (PAAQ, HADS-D, HADS-A, PMDD, negative parenting, and positive parenting) across various parent-child attributes, including the number of children, employment status, birth order, and child age.

Results exhibited no significant differences in depression, anxiety, or PMDD symptoms based on these attributes. However, differences were found in negative parenting, positive parenting, and psychological flexibility. Specifically, psychological flexibility was lower among unemployed parents compared to those on parental leave, and it was also lower among parents raising 2- and 3-year-olds compared to those with younger children. Additionally, parents on parental leave or in full-time employment, parents raising one child, and those raising younger children were less likely to engage in negative parenting behaviors. Parents on parental leave were more likely to engage in positive parenting than unemployed parents, and those raising their second child were more likely to engage in positive parenting than those raising their first child.

In Japan, several studies have highlighted the parenting stress experienced by mothers raising infants and toddlers [39]. Research has shown that unemployed mothers often feel more isolated and are more prone to losing their sense of identity [40]. Additionally, mothers raising 2- and 3-year-olds report greater stress related to managing anger and aggression toward their children compared to mothers of 1-year-olds [41]. This heightened stress may stem from children entering the "terrible twos" or primary rebellious period, during which their behavior becomes more defiant and argumentative [42]. Consequently, mothers’ psychological flexibility may decrease, making them more prone to engaging in negative parenting behaviors.

Based on these findings, mothers in Japan are more likely to increase their psychological flexibility, engage in less negative child-rearing behaviors, and engage in more positive child-rearing behaviors when they have social ties, such as child-rearing leave, compared to when they are unemployed. The number and age of children are also very important, and mothers raising two or three children or raising two- or three-year-olds are more likely to engage in negative parenting behaviors and need more support.

Pearson’s correlation coefficients were calculated for each scale score: the HADS-D, HADS-A, PAAQ, negative parenting, positive parenting, and PMDD-total. 44), negative parenting and the PAAQ (r = .44), and HADS-A and the PAAQ (r = .54) showed moderate positive correlations. Miyaoka et al. [37] surveyed menstruating 20- to 45-year-olds (of whom 37% were women with children) and found a moderate positive correlation (r = .54) between PMDD symptoms and depression, which is consistent with the results of this study. Brassell et al. [43] found that raising 3- 5-year-old 210 subjects and found moderate (r = .40) and weak (r = .25) correlations between the AAQ-II, which measures psychological flexibility in general, not just parenting, negative parenting, and positive parenting. Fonseca et al. [44] studied 250 mothers with children aged 2–12 years and found moderate correlations between the AAQ-II and anxiety and depression (r = .43, r = .47) and moderate correlations with a parenting style that uses corporal punishment (authoritative) (r=-.46). For the PAAQ, which measures psychological flexibility related to parenting used in this study, the moderate correlation with negative parenting is consistent with previous studies. By contrast, positive parenting was not correlated with the PAAQ in the present study, whereas in a previous study [43], permissive parenting style and AAQ-II were weakly correlated. This may be because in positive parenting, given that PAAQ functioned as a regulating variable, there were many surplus variables, although related, that did not show up in the correlation.

We examined whether the PAAQ functions as a moderating variable for PMDD and depression, anxiety, and positive and negative parenting and found that it is a moderating variable for anxiety and positive parenting. When PMDD symptoms were high, psychological inflexibility resulted in higher anxiety and less Positive Parenting; when PMDD symptoms were low and psychological inflexibility was present, anxiety was low, and Positive Parenting was increased. Additionally, for those with low PMDD symptoms, Positive Parenting was not influenced by psychological flexibility, whereas for those with high PMDD symptoms, Positive Parenting was highly influenced by psychological flexibility; if inflexible, Positive Parenting was not possible. This indicates that even mothers with PMDD symptoms can be positively involved with their children if they have high psychological flexibility.

Depression and negative parenting were associated with higher psychological flexibility regardless of PMDD symptoms. These findings indicate that PMDD symptoms do not influence depression or negative parenting, even when controlling for child and maternal attributes, but rather psychological flexibility. Although few studies have examined maternal psychological flexibility and nurturing behaviors during infancy, a study by Brassell et al. [43] of 210 mothers raising 3- to 5-year-olds found that parental role-specific psychological flexibility had a strong influence on adaptive nurturing behaviors and harsh discipline practices, a moderate negative impact on lax discipline practices and negative parenting, and a weak positive impact on positive parenting. The influence of psychological flexibility on nurturing behaviors is similar to the results of the present study. In a study conducted on 250 mothers with children aged 2–12 years [44], even after controlling for anxiety and depression, distress about the parenting role positively affected authoritative parenting style through the mediation of psychological flexibility and authoritarian parenting style, and negatively affected permissive parenting style (authoritative parenting style and authoritarian parenting style also had a direct effect on distress about parenting roles). (Authoritative and authoritarian parenting styles also directly affected distress related to parental roles). The fact that psychological flexibility was a mediating variable in this study, as positive parenting is a concept similar to authoritative parenting style and negative parenting is similar to authoritarian parenting style, is similar to the results of the present study, the results are similar to those of the present study.

Therefore, in mothers raising children aged 0 to 3 years, increased psychological flexibility positively influences maternal mental health and nurturing behaviors. The findings of this study further suggest that even among mothers with high PMDD symptoms, greater psychological flexibility may help reduce anxiety and promote positive parenting. Given that approximately 18% of the mothers in this study were diagnosed with PMDD or PMS, providing psychological support to enhance psychological flexibility is crucial, as one in five mothers is affected by hormonal fluctuations.

In Japan today, possible facilities for working with mothers raising children aged 0–3 include day-care centers, local childcare centers, and gynecology departments for the treatment of PMDD. Among them, obstetrics and gynecology departments that provide one-month checkups, pediatrics departments that provide checkups for 0-year-olds, and health centers that provide checkups for 1–6 months and 3-year-olds may be more likely to offer programs related to mothers' mental health. In the future, early intervention and prevention programs using ACT programs should be subject to empirical studies to increase psychological flexibility and prevent negative parenting.

4.1 Limitations

The first limitation of this study is its cross-sectional design, which limits the ability to infer causal relationships. While the direction of associations explored in the adjustment model aligns with prior literature, the influence of psychological flexibility and its moderating effects were only examined within this framework. Without testing these relationships in a longitudinal design, definitive conclusions about causality cannot be drawn. Future longitudinal studies on PMDD symptoms, psychological flexibility, nurturing behaviors, and emotional problems are essential for a clearer understanding of these dynamics.

A second limitation is the exclusive focus on mothers. Emotional problems in mothers have been linked to their relationships with their partners, their support systems, and their children's developmental characteristics. Future studies should investigate whether mothers of children with developmental disorders, such as autism, fit within the model used in this study. This would require controlling for factors such as marital relationships, support networks, and other contextual influences.

A third limitation is the low Cronbach's α coefficient for the depression subscale of the HADS (α = .59-.61). While some researchers in the social sciences consider a Cronbach's α above .60 acceptable [45], the recommended threshold is generally .70 or higher. Therefore, caution is warranted when interpreting these results. The HADS was used in this study because it measures both anxiety and depression, but future research should consider using scales with higher reliability and validity when assessing depressive symptoms.

This study’s results suggest that improving the psychological flexibility of parents raising infants and young children, regardless of whether they have PMDD symptoms, may positively impact their mood and parenting behaviors. Future research should explore the intervention effects of ACT for parents raising children to better understand its potential benefits.

PMDD – Premenstrual Dysphoric Disorder

PMS – Premenstrual Syndrome

HADS – Hospital Anxiety and Depression Scale

HADS-D – Hospital Anxiety and Depression Scale (Depression subscale)

HADS-A – Hospital Anxiety and Depression Scale (Anxiety subscale)

PAAQ – Parental Acceptance and Action Questionnaire

ACT – Acceptance and Commitment Therapy

AAQ-II – Acceptance and Action Questionnaire-II

Ethics approval and consent to participate

This study was approved by the Research Ethics Committees of the University of Tokyo Health Sciences (17-27H) and Rikkyo University (21-31). Consent to participate in the study was obtained from the participants before participating in the study.

Consent for publication

The author have read and agreed to the published version of the manuscript.

Availability of data and materials

Data utilized in this study is available upon request from the corresponding author.

Competing interests

I.O. received grants from NEC solution Innovators Ltd., and Infocom Co.; Lecture fees from Otsuka Pharmaceutical Co., Ltd., MSD K. K., Eisai Co., Ltd.; and consultation fees from NEC solution Innovators Ltd. And Suntory Wellness Ltd for projects unrelated to the submitted work. J.O. received grants from NEC Solution Innovators, Inc. but NEC Solution Innovators, Inc. Ltd. is not associated with any profit from the results of the submitted paper. The authors declare having no competing interests.

Funding

This work was supported by Grants-in-Aid for Scientific Research–KAKENHI–Early-Career Scientists (Grant Number: 25309).

Authors' contributions

Writing—original draft preparation, J.O.; writing—review and editing, I. O. ; supervision, IO.; project administration, J.O. and I.O.; funding acquisition, J.O.

Disclosure statement

None of the authors have any conflicts of interest related to this study.

Acknowledgements

We would like to thank Editage [http://www.editage.com] for editing and reviewing this manu-script for the English language.

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Psychological Flexibility as a Moderator of the Association Between Premenstrual Dysphoric Disorder, Depression, Anxiety, Positive Parenting, and Negative Parenting: A Cross-Sectional Study

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Abstract

Background

Methods

Results

Conclusions

Figures

1. Introduction

2. Method

2.1. Participants

2.2. Measures

2.2.1 Demographic information

2.2.2 Japanese version of the Parent Acceptance and Action Questionnaire (PAAQ-J [32])

2.2.3 Hospital Anxiety and Depression Scale (HADS [34]).

2.2.4 Premenstrual Dysphoric Disorder Scale (PMDDS; Miyaoka et al. [37])

2.2.5 Questionnaire on Dealing with Children (QDC; Shimada, Kayashima, & Suzuki [10])

2.3. Procedures

2.4. Data analysis

3. Results

3.1 Demographic data

3.2. Correlation coefficients among each scale

3.3. Moderation Analysis

4. Discussion

4.1 Limitations

5. Conclusion

Abbreviations

Declarations

References

Tables

Supplementary Files

Status:

Journal Publication

Version 1