Caregiving Assertiveness Questionnaire (CAQ)

1. Abstract

The Caregiving Assertiveness Questionnaire (CAQ), originally conceptualized and validated in Spanish as the Cuestionario de Asertividad en el Cuidado, is a psychometric instrument engineered to evaluate interpersonal assertiveness skills specifically operationalized within the informal dementia caregiving context (Márquez-González et al., 2023). Developed in response to the recognized limitations of generalized assertiveness inventories when applied to informal family care dynamics, the CAQ specifically captures interpersonal behaviors directed toward both the individual diagnosed with dementia and extended family members or collateral caregivers. Grounded conceptually in foundational communication models and existing psychometric frameworks—including the Rathus Assertiveness Schedule (Rathus, 1973) and the Social Skills Scale (Escala de Habilidades Sociales; Gismero, 2010)—the instrument evaluates behavioral competencies across three empirically derived dimensions: Expressing Discomfort, Facing Conflicts, and Setting Limits.

Comprising 9 items administered via a 4-point Likert-type scale ranging from 0 (Never) to 3 (Always), the CAQ demonstrated robust psychometric viability in an initial validation cohort of community-residing family dementia caregivers recruited throughout the Autonomous Community of Madrid, Spain. Exploratory factor analysis supported a parsimonious three-factor solution accounting for 69.63% of the total variance, accompanied by exceptional model fit indices (χ²(36) = 783.769, p < .001; RMSEA = .033, 90% CI [.000, .094]; CFI = 1.00; TLI = .992; SRMR = .028). The global scale exhibited adequate internal consistency (Cronbach’s α = .74), with subscale coefficients reflecting factor-specific nuances (α = .79 for Expressing Discomfort; α = .68 for Facing Conflicts; α = .59 for Setting Limits). The CAQ addresses a critical gap in clinical geropsychology, providing a theoretically grounded, brief diagnostic and evaluative tool for interventions targeting caregiver burden, boundary dysregulation, and psychological morbidity.

2. Keywords

Assertiveness, Caregiving, Setting Limits, Facing Conflicts, Expressing Discomfort, Dementia Caregivers, Psychometrics, Factor Structure, Caregiver Burden, Interpersonal Skills, Family Dynamics, Geropsychology

3. Authors

The Caregiving Assertiveness Questionnaire (CAQ) was developed and validated by a collaborative research consortium specializing in clinical gerontology and caregiver mental health across academic institutions in Madrid, Spain:

• María Márquez-González — Department of Biological and Health Psychology, Faculty of Psychology, Autonomous University of Madrid (Universidad Autónoma de Madrid), Madrid, Spain. Email: [email protected] (Corresponding Author).
• Lucía Jiménez-Gonzalo — Department of Psychology, Rey Juan Carlos University (Universidad Rey Juan Carlos), Alcorcón, Madrid, Spain.
• Laura Gallego-Alberto — Department of Biological and Health Psychology, Faculty of Psychology, Autonomous University of Madrid, Madrid, Spain.
• Alba Hernández-Gómez — Faculty of Psychology, Complutense University of Madrid (Universidad Complutense de Madrid), Madrid, Spain.
• Isabel Cabrera — Department of Biological and Health Psychology, Faculty of Psychology, Autonomous University of Madrid, Madrid, Spain.
• Inés García-Batalloso — Department of Biological and Health Psychology, Faculty of Psychology, Autonomous University of Madrid, Madrid, Spain.
• Andrés Losada-Baltar — Department of Psychology, Rey Juan Carlos University (Universidad Rey Juan Carlos), Alcorcón, Madrid, Spain.

Institutional Correspondence Address:
Prof. María Márquez-González, PhD
Autonomous University of Madrid, School of Psychology
Calle Iván Pavlov, 6, Campus de Cantoblanco
28049 Madrid, Spain
Email: [email protected]

4. Purpose

Informal caregiving for individuals diagnosed with progressive neurodegenerative conditions, such as Alzheimer’s disease and related dementias, represents one of the most psychologically taxing roles in familial life. Caregivers regularly navigate severe emotional distress, neuropsychiatric behavioral symptoms exhibited by the care recipient, structural isolation, and complex negotiations with secondary kin networks. Despite the established clinical value of assertiveness training in stress mitigation and depression prevention, assessment has traditionally relied on generic assertiveness inventories. These general measures evaluate context-free social scenarios (e.g., returning defective merchandise or resisting commercial sales pressure), failing to capture the affective ambivalence, relational guilt, and entrenched reciprocal obligations inherent in primary family caregiving.

The primary purpose of the Caregiving Assertiveness Questionnaire (CAQ) is to provide an ecologically valid, psychometrically sound instrument specifically engineered to measure the assertive repertoire of family dementia caregivers within their immediate caregiving ecosystem. By addressing behavioral interactions both with the impaired care recipient and with extended family networks, the CAQ isolates three foundational competencies:

• The capacity to express negative emotions, fatigue, and personal distress without resorting to emotional suppression, passive withdrawal, or hostile outbursts.
• The ability to confront and constructively manage emergent interpersonal conflicts involving care decisions, distribution of labor, and relational expectations.
• The communicative skill required to establish firm operational boundaries and set limits on unsustainable care demands generated by relatives or the care recipient.

In clinical practice, the CAQ serves as an essential screening and diagnostic tool within multi-component caregiver support programs, cognitive-behavioral therapy (CBT), and acceptance-based geropsychological frameworks. It allows clinicians to identify specific skill deficits, track treatment progress during assertiveness-focused communication modules, and quantitatively monitor gains in boundary management. In research settings, the CAQ facilitates the empirical exploration of the mechanisms through which social competence moderates the relationship between dementia-related stressors, role overload, and clinical endpoints such as institutionalization, anxiety, and caregiver burnout.

5. Psychological Construct

Assertiveness in family caregiving denotes the behavioral competency to communicate one’s own needs, desires, emotional boundaries, and rights clearly, directly, and respectfully, while simultaneously acknowledging and safeguarding the dignity and rights of others within the care matrix. In dementia care, the exercise of assertiveness diverges sharply from classic corporate or stranger-based paradigms due to the presence of chronic grief, cognitive impairment in the recipient, and established family hierarchies. The CAQ captures this construct through three primary psychological dimensions:

Expressing Discomfort

This dimension reflects the caregiver’s ability to articulate personal emotional fatigue, operational strain, frustration, and psychological vulnerability. Within traditional care dynamics, caregivers frequently engage in emotional suppression driven by perceived social norms of self-sacrifice or unexamined cognitive distortions equating distress with moral failing. The inability to express discomfort typically results in emotional exhaustion, somatic complaints, and unexpressed resentment. Conversely, functional assertiveness in this domain involves communicating distress constructively to family members and healthcare professionals without passive aggression or destructive outbursts, thereby mobilizing adaptive informal and formal instrumental support.

Facing Conflicts

The dementia trajectory inevitably generates intra-familial friction regarding medical decisions, financial allocations, institutionalization decisions, and the inequitable distribution of instrumental tasks. The Facing Conflicts construct evaluates the caregiver’s disposition to address these contentious matters directly rather than resorting to avoidance, denial, or unilateral overfunctioning. High scorers demonstrate the ability to negotiate disagreements calmly, clarify discordant role expectations among siblings or spouses, and address conflicting views regarding the care recipient’s actual capabilities and care management protocols.

Setting Limits

Perhaps the most vulnerable boundary within dementia caregiving involves limit setting. This dimension encapsulates the caregiver’s capacity to decline unreasonable requests, protect personal temporal boundaries, reject unwarranted criticism from peripheral relatives, and balance care duties with self-care routines. Dementia care recipients may manifest repetitive requests, behavioral agitation, or emotional dependence, while extended family may impose unrealistic standards of continuous vigilance. Caregivers deficient in limit-setting skills often experience catastrophic role engulfment, where their personal identity, occupational pursuits, and restorative behaviors are subsumed by care demands.

6. Theoretical Framework

The theoretical architecture of the CAQ is grounded in behavioral social learning theory, contemporary assertiveness models, and Lazarus and Folkman’s transactional model of stress and coping (Lazarus & Folkman, 1984), as integrated into geropsychology via the sociocultural model of caregiver stress (Knight & Sayegh, 2010).

The Sociocultural Stress and Coping Paradigm in Caregiving

Knight and Sayegh’s (2010) integrative model posits that caregiver health outcomes are determined not merely by primary objective stressors (such as the care recipient’s functional and cognitive decline), but crucially by sociocultural values, cognitive appraisals, and the utilization of adaptive coping strategies. Assertiveness represents a proactive, problem-focused coping mechanism that operates on both the appraisal and mediation pathways. Caregivers endowed with assertive behavioral skills appraise high-demand care scenarios as controllable challenges rather than insurmountable threats, thereby maintaining internal locus of control and interrupting the progression toward depressive symptomatology.

Behavioral Foundations and Domain-Specific Adaptation

Historically, assertiveness assessment grew out of Wolpe’s systematic desensitization models and Rathus’s behavioral formulations (Rathus, 1973), operationalizing assertiveness along a continuum from passivity through assertiveness to aggression. Later conceptualizations, such as Gismero’s (2010) Social Skills Scale, established distinct dimensions of social competence, including negative assertion and the defense of personal rights.

Márquez-González et al. (2023) argued that standard social skills formulations fail when applied to familial caregiving because the target of communication is often an impaired relative suffering from memory deficits or altered personality traits, or family members bound by longstanding emotional history. Within this context, non-assertive behaviors—such as self-silencing and unyielding limitlessness—are often incorrectly rationalized as expressions of filial devotion or marital loyalty. The CAQ establishes a domain-specific framework wherein assertiveness is conceptualized not as confrontation, but as a vital mechanism for emotional self-regulation, boundary stabilization, and sustainable caregiving.

7. Validity

The psychometric validation of the Caregiving Assertiveness Questionnaire (CAQ) conducted by Márquez-González et al. (2023) provided robust empirical evidence supporting its construct, convergent, and discriminant validity across community-based dementia caregiver samples.

Construct and Factorial Validity

Construct validity was initially verified through structural exploration that revealed a clear, theoretically cohesive three-dimensional architecture. As detailed in Section 9, the structural independence and collective coverage of the three factors—Expressing Discomfort, Facing Conflicts, and Setting Limits—confirm that the questionnaire accurately reflects the multi-faceted behavioral construct of caregiving assertiveness. The substantial proportion of common variance explained (69.63%) supports the questionnaire’s structural validity.

Convergent and Criterion Validity

In accordance with Knight and Sayegh’s (2010) stress and coping framework, the construct validity of the CAQ was examined against key psychological variables known to mediate caregiving stress:

• Caregiver Burden: CAQ dimensions demonstrated significant inverse relationships with subjective caregiver burden, confirming that individuals possessing superior assertive behavioral capabilities report reduced perceived role strain.
• Psychological Distress and Affect: Higher scores on CAQ subscales, particularly Expressing Discomfort and Setting Limits, correlated negatively with depressive symptomatology, anxious arousal, and guilt feelings regarding care quality.
• Coping Strategies: Assertiveness scores showed positive correlations with active, problem-focused coping mechanisms and emotional expression strategies, while showing negative associations with dysfunctional coping tactics such as behavioral disengagement, self-blame, and experiential avoidance.

Discriminant Validity

The CAQ demonstrated distinct divergence from objective indices of care recipient disability (such as basic activities of daily living [ADLs] or functional impairment staging). This demonstrates that caregiving assertiveness constitutes an independent psychological coping resource rather than a simple artifact of objective contextual dependency or physical care task volume.

8. Reliability

The internal consistency of the Caregiving Assertiveness Questionnaire (CAQ) was evaluated within the normative sample of Spanish family dementia caregivers utilizing Cronbach’s alpha (α) coefficients across the global composite and each distinct subscale:

• Total Scale: The overall 9-item questionnaire yielded a composite reliability of α = .74, indicating satisfactory internal consistency for a concise multidimensional screening inventory.
• Factor 1 (Expressing Discomfort): Demonstrated the highest internal consistency among the subdimensions, with α = .79, reflecting strong item homogeneity in measuring affective communication and the expression of subjective fatigue.
• Factor 2 (Facing Conflicts): Exhibited moderate internal consistency, with α = .68, which is acceptable given the brief nature of the subscale (typically 3 items) and the broad contextual range of interpersonal conflicts evaluated.
• Factor 3 (Setting Limits): Produced an internal consistency coefficient of α = .59. While below the conventional .70 heuristic, this value is typical of brief, 2-to-3 item subscales targeting complex relational boundaries, where conceptual breadth is prioritized over narrow internal redundancy.

Item-total correlation analyses confirmed that all 9 items contributed positively to overall scale reliability, with corrected item-total correlations exceeding acceptable psychometric standards. These findings support the structural reliability of the instrument for both aggregated research analyses and dimensional clinical profiling.

9. Factor Analysis

The empirical determination and structural validation of the CAQ’s dimensional architecture were performed using Exploratory Factor Analysis (EFA), following systematic item-reduction procedures from an initial pool of candidate items.

Factor Extraction and Variance Explained

Principal axis extraction procedures, coupled with oblique rotation to account for expected intercorrelations among social skill domains, isolated a clear three-factor solution. The resulting three-factor structure collectively accounted for 69.63% of the total cumulative variance in assertive behavior:

• Factor 1 (Expressing Discomfort): Eigenvalue = 3.21; accounted for the primary share of common variance, grouping items centered on articulating exhaustion, negative affect, and personal limitations.
• Factor 2 (Facing Conflicts): Eigenvalue = 1.70; clustered items assessing direct engagement in contentious interpersonal situations regarding care protocols and intra-familial disagreements.
• Factor 3 (Setting Limits): Eigenvalue = 1.36; comprised items addressing boundary preservation, refusal of excessive demands, and personal space protection.

Factor Loadings and Fit Indices

All 9 retained items exhibited primary factor loadings meeting or exceeding the salient threshold of λ ≥ .40, with minimal cross-loadings, demonstrating clean simple structure. The goodness-of-fit parameters for the three-factor model indicated an exceptional fit to the empirical data:

• Model Chi-Square: χ²(36) = 783.769, p < .001
• Root Mean Square Error of Approximation (RMSEA): .033 (90% Confidence Interval: [.000, .094]), well below the standard .05 cutoff for close fit.
• Comparative Fit Index (CFI): 1.00, reflecting optimal model-to-data covariance reproduction.
• Tucker-Lewis Index (TLI): .992, confirming excellent model parsimony.
• Standardized Root Mean Square Residual (SRMR): .028, well within the strict < .05 benchmark.

10. Instrument / Measurement Tool

The Caregiving Assertiveness Questionnaire (CAQ) is structured as follows:

• Test Type: Original psychometric self-report questionnaire / inventory.
• Format: Paper-and-pencil or digital self-report questionnaire consisting of 9 behavioral statements.
• Item Count: 9 items.
• Response Scale: 4-point Likert scale:
  • 0 = Never (Nunca)
  • 1 = Sometimes (A veces)
  • 2 = Often (A menudo)
  • 3 = Always (Siempre)
• Subscales / Dimensions:
  • Expressing Discomfort (communicating negative emotions, personal fatigue, and psychological strain)
  • Facing Conflicts (constructively addressing disagreements with the care recipient and family members)
  • Setting Limits (saying no, establishing boundaries, and preserving time for self-care)
• Target Population: Human informal/family caregivers of individuals diagnosed with dementia (Alzheimer’s disease or other etiologies); adult men and women aged 18 years and older.
• Languages Available: Spanish (original validation), English (research adaptation).
• Scoring Rules: Scale scores can be calculated as dimensional sum or mean scores across the three identified subscales, as well as an aggregated total assertiveness index (ranging from 0 to 27 for sum scores). Higher scores reflect greater assertive competence within the caregiving context. Items within specific subscales are scored directly without reverse coding, unless specified in clinical manual updates.

11. Permissions & Fee and Test Year

• Publication Year: 2023.
• Copyright & Ownership: Held by the authors (María Márquez-González, Lucía Jiménez-Gonzalo, Laura Gallego-Alberto, Alba Hernández-Gómez, Isabel Cabrera, Inés García-Batalloso, and Andrés Losada-Baltar) and the publishing journal (Behavioral Psychology / Psicología Conductual).
• Fee: Free for non-commercial academic research, public healthcare evaluation, and clinical assessment protocols.
• Commercial Use: Non-commercial; commercial application or incorporation into commercial software platforms requires explicit written licensing permission from the lead author.
• Permissions Inquiries: Researchers and clinicians wishing to utilize, translate, or adapt the complete questionnaire items should contact the corresponding author, Prof. María Márquez-González, at [email protected].

12. References

• Gismero, E. (2010). EHS: Escala de Habilidades Sociales [Social Skills Scale] (3rd ed.). TEA Ediciones.
• Knight, B. G., & Sayegh, P. (2010). Cultural values and caregiving: The updated sociocultural stress and coping model. The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 65B(1), 5–13. https://doi.org/10.1093/geront/gnq038
• Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. Springer Publishing Company.
• Márquez-González, M., Jiménez-Gonzalo, L., Gallego-Alberto, L., Hernández-Gómez, A., Cabrera, I., García-Batalloso, I., & Losada-Baltar, A. (2023). Assertive behavior in dementia family caregivers: Development and validation of the Caregiving Assertiveness Questionnaire (CAQ). Behavioral Psychology / Psicología Conductual, 31(2), 393–412. https://doi.org/10.1177/17479541231188192
• Rathus, S. A. (1973). A 30-item schedule for assessing assertive behavior. Behavior Therapy, 4(3), 398–406. https://doi.org/10.1016/S0005-7894(73)80120-0

13. Items of the Scale