Composite Caregiving Questionnaire (CCQ)

The CCQ is intended to provide clinicians with information about caregivers’ perceptions of their caregiving role and their thoughts and feelings about their child.  It is not designed to categorise parent-child attachment relationships, but it provides important information about factors related to child attachment security that can inform the assessment process and help with treatment planning. The CCQ can also be used to monitor outcomes of attachment-based treatments that are focused on shifting the cognitive aspects of caregiving associated with attachment security. 

Each scale of the CCQ is scored separately. A total score is not computed.

• Empathy & Understanding (items 4 – 9): a total raw score from 0 – 60. A higher score indicates more empathic parenting. A cutoff score below 38 indicates possible clinical concern.
• Emotion & Affection (items 10 – 15; item 15 is reverse-scored): a total raw score from 0 – 60. A higher score indicates more affectionate parenting. A cutoff score below 47 indicates possible clinical concern.
• Hostility (items 16 – 20): a total raw score from 0 – 50. A high score indicates more parental hostility. A cutoff score of above 21 indicates possible clinical concern. 
• Caregiving Helplessness (items 21 – 27): a total raw score from 7 – 35. A high score indicates more parental helplessness. A cutoff score of above 16 indicates possible clinical concern.
• Parental Mentalising (items 28 – 45; items 31, 36, 41 are reverse-scored): a total raw score from 0 – 54. A high score indicates keeping the child more in mind and thinking about own childhood more. A cutoff score below 31 indicates possible clinical concern. The Parental Mentalising scale has three subscales:
  • Cue Recognition (items 28, 31, 33, 36, 39, 41, 44): being aware of the child’s needs and wants
  • Mentalisation of Infant (items 29, 32, 35, 37, 40, 43, 45): being aware of child’s own internal world
  • Own Childhood Experience (items 30, 34, 38, 42): an awareness of the parents’ own childhood experiences

Normative percentiles are presented from a community sample of parents/caregivers of children aged between 1 and 4 (Byron & Hawkins, 2022). A percentile of 50 indicates that the individual’s scores are average when compared to other parents/caregivers. 

A scaled score (out of 10) is presented for the Parental Mentalising subscales so that a comparison can be made between them (given there are different numbers of items between each one).  

The CCQ is made up of 5 subscales selected from already validated measures that assess constructs associated with attachment security in young children. Subscales were selected because of their ease of administration and scoring and theoretical alignment with precursors of attachment relationships (Maxwell, McMahon, Huber, Reay et al., 2021). Original scale authors granted permission for each subscale to be included in this composite questionnaire. The information below shows the origins of questionnaire items and subscales. Questionnaire items aimed at parents of infants were reworded to be relevant for parents of children 0 – 6 years.

• Empathy & Understanding: taken from empathy and understanding subscale of the Tool to Measure Parenting Self-Efficacy (TOPSE; Kendall & Bloomfield, 2005). Items = 6.
• Emotion & Affection: taken from emotion and affection subscale of the TOPSE (Kendall & Bloomfield, 2005). Items = 6.
• Caregiving Helplessness: taken from Helpless subscale of Caregiving Helplessness Questionnaire (CHQ; George & Solomon, 2011). Items = 7
• Hostility: taken from Hostile Parenting scale, The Longitudinal Study of Australian Children (LSAC; 2006). Items = 5
• Parental Mentalising: taken from Diamond Maternal Reflective Functioning Scale (Diamond et al. 2013). Items = 18

Parent self-efficacy. The initial TOPSE development study suggested good internal consistency of each subscale, with good internal consistency for the empathy (alpha = 0.89) and affection subcales (alpha = 0.81) in a sample of 63 parents of children 0 – 6 years (Kendall & Bloomfield, 2005). A systematic review of self-reported parenting self-efficacy measures also concluded that the TOPSE had good content validity and acceptable construct validity (Wittkowski et al., 2017). 

Caregiving helplessness.  The original scale development study revealed good factor structure for the measure’s three subscales in a sample of 208 mothers of children aged 3 – 11 years. The helpless subscale showed good internal consistency (alpha = 0.85), and convergent and divergent validity in a smaller subset of the larger sample (George & Solomon, 2011). Specifically, the helpless subscale was significantly related to helplessness ratings from interviews, and not significantly related to mothers’ stress levels in non-caregiving domains, such as stress about health. A subsequent validation study showed good internal consistency of the helpless subscale with mothers of infants (alpha = 0.80; Huth-Bocks, Guyon-Harris, Calvert, Scott & Harris, 2016), and good convergent validity with concurrent measures of maternal risk factors and infant problems. The helpless subscale was correlated with maternal BDI-II depression (r = 0.53), maternal PCL post-traumatic stress symptoms (r = 0.53), and infant problems as measured by the BITSEA (r = 0. 32).

Hostility. The hostility subscale was developed for use in the Longitudinal Study of Australian Children (LSAC, 2006), which is a large, longitudinal study following the development of 10,000 children and families from all parts of Australia. It has shown good internal consistency, with H coefficients ranging from 0.85 to 0.92 across multiple waves of the LSAC (Giallo, Cooklin, Wade, D’Esposito, & Nicholson, 2013). It has also shown predictive validity with significant associations with child outcomes in major population-based studies.

Parental mentalising. The parent mentalising scale was developed and validated on a sample of 219 mothers of infants (Diamond, Caltabiano, Caltabiano, & Goodman, 2013). It showed acceptable internal consistency and evidence of convergent and divergent validity.  

The CCQ was piloted for use as a tool for monitoring outcomes of attachment-based interventions in a non-randomized waitlist control trial examining the effectiveness of Circle of Security Parenting (Maxwell, McMahon, Huber, Reay et al., 2021).  In this sample of 255 parents of children aged 0-6 years, internal consistency of all subscales was good (alphas ranged from 0.78 to 0.88). Associations among subscales aligned as expected, supporting convergent validity of the subscales. For example, hostility was positively correlated with caregiving helplessness (r = 0.56) and negatively with empathy (r = -0.40) and affection (r = -0.38); empathy was positively correlated with affection (r = 0.66); caregiving helplessness was negatively correlated with empathy (r = -0.57) and affection (r = -0.50); and parent mentalising was positively correlated with empathy (r = 0.45) and affection (r = 0.30). All subscales successfully differentiated treatment from waitlist control group in the study, and all were sensitive to change in the intervention group.

A study by Byron & Hawkins (2022) using the CCQ with a community sample of 80 parents/caregivers of children aged between 1 and 4 (mean age 2) found the following means (and standard deviations):

• Empathy & Understanding: mean = 48.3 (9.3)
• Emotion & Affection: mean = 54.7 (9.98)
• Hostility: mean = 11.6 (9.2)
• Caregiving Helplessness: mean = 9.4 (3.4)
• Parental Mentalising: mean = 37.7 (6.2)

Percentiles are computed using percentile tables from Byron & Hawkins (2022), with the exception of the Affection scale, where simple mean and standard deviation were used to compute norms given data artefacts in the percentile table.

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