The Metacognitions Questionnaire and Its Derivatives in Children and Adolescents: A Systematic Review of Psychometric Properties

Relationships between metacognitive beliefs and anxiety and depression in children and adolescents: A meta-analysis

BACKGROUND

As hypothesized in the Self-Regulatory Executive Function (S-REF) model, metacognitive beliefs are associated with anxiety and depression in adults. An important question is the extent to which such effects are present in children and adolescents, with the implication that the model may also apply to young people. The aim of this meta-analysis was to synthesize results on the nature and magnitude of associations between metacognitive beliefs and anxiety and depression in children and adolescents.

METHODS

Systematic searches were conducted to identify studies that investigated: (1) group differences in metacognitive beliefs in clinical compared to non-clinical samples or (2) correlations between metacognitive beliefs and symptoms of anxiety and depression.

RESULTS

Forty papers were identified comprising a total sample of 9,887 participants aged 7-18 years. Meta-analyses revealed that clinical samples endorsed significantly elevated metacognitive beliefs on four out of the five domains measured (i.e., negative beliefs about worry, cognitive confidence, need for control, and cognitive self-consciousness, with the only exception being positive beliefs about worry) compared to non-clinical samples with a small to large effect (Hedges' gs = 0.45-1.22). Moreover, all five domains of metacognitive beliefs were significantly and positively correlated with symptoms of anxiety and depression of a small to large effect (rs = .24-.53). Negative beliefs about worry showed the strongest relationship with clinical status and the magnitude of symptoms.

LIMITATIONS

The number of studies did not allow for an evaluation of metacognitive beliefs at a disorder-specific level.

CONCLUSIONS

In line with the S-REF model, our findings provide evidence of robust cross-sectional relationships between metacognitions and both anxiety and depression in childhood and adolescence.

Cardiac rehabilitation for children and young people (CardioActive): protocol for a single-blind randomised feasibility and acceptability study of a centre-based cardiac rehabilitation programme versus usual care in 11-16 years with heart conditions

BACKGROUND

Congenital heart conditions are among the most common non-communicable diseases in children and young people (CYP), affecting 13.9 million CYP globally. While survival rates are increasing, support for young people adjusting to life with a heart condition is lacking. Furthermore, one in three CYP with heart conditions also experiences anxiety, depression or adjustment disorder, for which little support is offered. While adults are offered cardiac rehabilitation (CR) to support their mental and physical health, this is not offered for CYP.One way to overcome this is to evaluate a CR programme comprising exercise with mental health support (CardioActive; CA) for CYP with heart conditions. The exercise and mental health components are informed by the metacognitive model, which has been shown to be effective in treating anxiety and depression in CYP and associated with improving psychological outcomes in adult CR.

METHOD AND ANALYSIS

The study is a single-blind parallel randomised feasibility trial comparing a CR programme (CA) plus usual care against usual care alone with 100 CYP (50 per arm) aged 11-16 diagnosed with a heart condition. CA will include six group exercise, lifestyle and mental health modules. Usual care consists of routine outpatient management. Participants will be assessed at three time points: baseline, 3-month (post-treatment) and 6-month follow-up. Primary outcomes are feasibility and acceptability (ie, referral rates, recruitment and retention rates, attendance at the intervention, rate of return and level of completion of follow-up data). Coprimary symptom outcomes (Strength and Difficulties Questionnaire and Paediatric Quality of Life) and a range of secondary outcomes will be administered at each time point. A nested qualitative study will investigate CYP, parents and healthcare staff views of CR and its components, and staff's experience of delivering CA. Preliminary health economic data will be collected to inform future cost-effectiveness analyses. Descriptive data on study processes and clinical outcomes will be reported. Data analysis will follow intention to treat. Qualitative data will be analysed using thematic analysis and the theoretical framework of acceptability.

ETHICS AND DISSEMINATION

Ethical approval was granted on 14 February 2023 by the Greater Manchester East Research Ethics Committee (22/NW/0367). The results will be disseminated through peer-reviewed journals, conference presentations and local dissemination.

TRIAL REGISTRATION NUMBER

ISRCTN50031147; NCT05968521.

Experience sampling methodology study of anxiety and depression in adolescents with epilepsy: The role of metacognitive beliefs and perseverative thinking

Emotional distress is common in young people with epilepsy (YPwE). According to the Self-Regulatory Executive Function (S-REF) model, maladaptive metacognitive beliefs and perseverative thinking are fundamental in the development and maintenance of emotional distress. As emotional distress and perseverative thinking can highly fluctuate over short intervals in YPwE, it is important to account for this variability when testing the utility of psychological models. Experience sampling methodology (ESM) was therefore used to explore the momentary relationship between metacognitive beliefs, perseverative thinking, and emotional distress in YPwE. Eighteen participants diagnosed with epilepsy (aged 12-17 years) completed the 10-day ESM period. Participants were prompted to complete the ESM assessment five times daily. The ESM assessment assessed participant's momentary levels of metacognitive beliefs, perseverative thinking (i.e., worry and rumination), and emotional distress (i.e., anxiety and depression). A series of multilevel regression analyses indicated that metacognitive beliefs were significantly positively associated with worry, rumination, anxiety and depression. After controlling for worry and rumination, respectively, metacognitive beliefs did not account for additional variance in anxiety or depression. Findings provide preliminary support for the utility of the S-REF model for emotional distress in YPwE. Metacognitive therapy, which is underpinned by the S-REF model, may be an appropriate intervention for emotional distress in YPwE. Future studies should assess the mediational relationship between metacognitive beliefs, perseverative thinking, and emotional distress using time-lagged models.

Trait Anxiety, Emotion Regulation, and Metacognitive Beliefs: An Observational Study Incorporating Separate Network and Correlation Analyses to Examine Associations with Executive Functions and Academic Achievement

Trait anxiety, emotion regulation strategies, and metacognitive beliefs influence executive functions (EFs) and academic achievement. This study examines their interplay and impact on academic success. In total, 275 adolescents (10-17 years) and parents completed an online questionnaire assessing trait anxiety, emotion regulation strategies, metacognition, parent-reported behaviors related to executive functioning, and overall school average. Preliminary analyses confirmed consistency with the existing literature for each variable and their interaction. Furthermore, we conducted a network analysis among the main variables. This analysis supports the need to pay more attention to reflective variables-maladaptive emotion regulation strategies and metacognitive beliefs about worry-when studying trait anxiety. These variables were linked to problematic executive functioning in adolescents, and the latter was negatively linked to academic achievement. This study offers innovative insights by investigating relationships less explored in the scientific literature. It reveals high and significant correlations between metacognitive beliefs, maladaptive emotion regulation strategies, and trait anxiety (r > 0.500, p < 0.001) but also between these variables and both executive functioning and academic achievement. These findings offer new perspectives for research and underscore the importance of holistically examining the psychological factors related to academic success.

Association between time perspective and metacognition among Lebanese adults: the mediating role of mindfulness

BACKGROUND

Mindfulness may serve as a component of metacognitive beliefs and can also be viewed as a form of time perspective. The interplay between time perspective and metacognitive beliefs remains understudied. Both aspects, however, display considerable stability over time and significantly influence an individual's life and well-being. Lebanon, marked by its diverse and complex history, struggles with various political, social, and economic challenges. This study offers a valuable and unprecedented opportunity to examine these connections within a distinct cultural context, shedding light on the unique experiences of the Lebanese population. Therefore, our research aims to investigate the connection between time perspective and metacognition, with a focus on the role of mindfulness as a mediator.

METHODS

This cross-sectional study was conducted from August to November 2022 and involved participants from various regions of Lebanon. The questionnaire included sociodemographic data and scales such as the Arabic versions of the 15-item Short Form of the Zimbardo Time Perspective Inventory, the Metacognitions Questionnaire, the Freiburg Mindfulness Inventory and the Acceptance and Action Questionnaire (AAQ-2).

RESULTS

Our investigation recruited 423 participants. The analysis showed that individuals with a positive stance on their past, a hedonistic present, or a future-oriented outlook exhibited heightened levels of mindfulness. This elevated state of mindfulness, in turn, demonstrated a significant link to augmented cognitive self-consciousness (An increased introspection into one's own thoughts). We also observed a direct association between a future-focused time perspective and high scores of cognitive self-consciousness. Furthermore, mindfulness emerged as a crucial mediator in the relationships between time perspectives and negative beliefs about the danger of worry. Similarly, individuals with a positive view on their past, a hedonistic present orientation, or a future-focused mindset demonstrated elevated levels of mindfulness, which was correlated with less negative beliefs about the danger of worry. Notably, a positive past perspective was directly associated with less negative views on worry and the subsequent loss of control, whereas higher future focused time perspective scores was significantly and directly associated with more negative beliefs about worry, whereas more future focused time perspective was significantly and directly associated with more negative beliefs about worry.

CONCLUSION

Our findings found several meaningful associations between our variables, but it primarily underscored the significance of considering distinct subcomponents within mindfulness and psychopathological metacognition that may overlap, shedding light on their differential impacts on psychological well-being. We were also able to mirror the dual pathway theory of time perspective suggested in previous studies. These insights carry notable implications for the development and refinement of mindfulness-based and metacognitive interventions, emphasizing the need for tailored approaches that consider varying time perspectives. Continued investigation in this area promises to advance our understanding of these constructs and refine their practical applications in mental health interventions and well-being enhancement strategies.

Validity and Reliability of the Metacognitions Questionnaire-30 (MCQ-30) among Chinese Adolescents

This study aimed to examine the psychometric properties of the Metacognitions Questionnaire-30 (MCQ-30) in a sample of Chinese adolescents (1382 boys, 1445 girls) aged 11 to 18 years. Confirmatory factor analysis was performed to assess factor structure, as well as, measurement invariance across demographic groups and clinical symptoms. The results of confirmatory factor analyses supported the original five-factor model. Configural, metric and scalar invariance of the five-factor model were also supported by gender, age, ethnicity, residence, parental education level, depression and anxiety status. Furthermore, all five subscales demonstrated good internal consistency (Cronbach alphas > 0.75) and test-retest reliability (intra-class correlation coefficients > 0.45). Finally, the five factors were positively related to symptoms of depression, anxiety, and irritability and negatively related to positive childhood experiences and life satisfaction, indicating excellent validity. The findings provide initial evidence that the MCQ-30 is a valid measure for use in Chinese adolescents.

Metacognition in schizophrenia: A practical overview of psychometric metacognition assessment tools for researchers and clinicians

Metacognition refers to the cognitive ability to control, monitor and modulate cognitive processes thus guiding and orienting behavior: a continuum of mental activities that ranges from more discrete ones, such as the awareness of the accuracy of others' judgment, to more integrated activities, such as the knowledge of cognitive processes. Metacognition impairment in schizophrenia, which is considered a core feature of the illness, has become a growing research field focusing on a wide range of processes including reasoning, autobiographical memory, memory biases, cognitive beliefs and clinical insight. There is a well-established relationship between metacognition and schizophrenia symptoms severity, as well as between impaired metacognitive functioning and specific symptomatic sub-domains, such as positive symptoms, negative symptoms, or disorganization. The development of specific cognitive-derived psychotherapies for metacognitive deficits in schizophrenia has been ongoing in the last years. Although sharing a metacognitive feature, these treatments focus on different aspects: false or unhelpful beliefs for metacognitive therapy; cognitive biases for metacognitive training; schematic dysfunctional beliefs for cognitive behavioral therapy (CBT) for psychoses; metacognitive knowledge and sense of identity for MERIT; interpersonal ideas or events triggering delusional thinking for MIT-P. This article reviews the instruments designed to assess metacognitive domains and functions in individuals with schizophrenia, providing mental health professionals with an overview of the heterogeneous current scenario ranging from self-administered scales to semi-structured interviews, which are supported by a variety of theoretical frameworks. Future directions may address the need for more specific and refined tools, also able to follow-up psychotherapeutic-induced improvements.

Comparison of Obsessive-Compulsive Disorder and Schizophrenia With Comorbid Obsessive-Compulsive Disorder in Terms of Insight, Metacognitive Beliefs, and Clinical Features

The aim was to compare insight levels into obsessive-compulsive symptoms (OCS), and metacognitions of patients with obsessive-compulsive disorder (OCD) and with schizophrenia with comorbid OCD (SZ-OCD). Thirty OCD patients and 30 SZ-OCD patients were evaluated; no significant difference was found between the groups in the Brown Assessment of Beliefs Scale (BABS) and the Metacognition Questionnaire-30 (MCQ-30). When all patients were divided into two groups regardless of the presence or absence of schizophrenia as "good insight" and "poor or no insight," the MCQ-30 total score was found to be higher in the "poor or no insight" group and showed a significant but moderate positive correlation with the BABS score. This study supports that the level of insight into OCS in SZ-OCD is not significantly different from patients with OCD. Metacognitions differ not according to the distinction between OCD and SZ-OCD but according to the level of insight in whole OCD sample.

Youth Metacognitive Therapy (YoMeta): protocol for a single-blind randomised feasibility trial of a transdiagnostic intervention versus treatment as usual in 11–16-year-olds with common mental health problems

Background

Mental health disorders in children and young people (CYP) are increasing but the provision of current evidence-based treatment for common mental health problems is limited. Treatment effects vary widely with no clear superiority of a single treatment approach. Further evaluation of contemporary and effective treatments in CYP is needed. Metacognitive therapy (MCT) has shown enhanced efficacy over ‘gold standard’ approaches in adult mental health, but so far has not been evaluated in a randomised trial of CYP. As such, we aim to assess the acceptability and feasibility of group-MCT for CYP with common mental health problems in comparison to usual treatment within Child and Adolescent Mental Health Services (CAMHS).

Method

YoMeta is a multicentre, two-arm, single-blind randomised feasibility trial comparing group-MCT to usual care in CYP with common mental health problems in CAMHS. CYP (target sample n = 100) with a common mental health problem will be recruited across at least three CAMHS services in the UK. Participants in the intervention arm will receive up to eight sessions of group-MCT delivered by a CAMHS mental health practitioner. The control arm will receive usual care in CAMHS which includes individual or group-based therapy. Feasibility will be assessed by the success of recruitment, retention, and data quality. Acceptability of the intervention will be assessed by the number of sessions attended and through qualitative interviews aimed at exploring CYP acceptability and understanding of the intervention. Symptoms of psychological distress will be assessed using the Revised Children Anxiety and Depression Scale (RCADS) at 20 weeks. We will also assess psychological well-being, symptoms of depression, metacognitive beliefs, quality of life, and measures to support economic evaluation (health status and health and social care use). Qualitative interviews will be conducted to understand practitioner’s views on training and delivery of group-MCT.

Discussion

The trial is designed to evaluate the acceptability and feasibility of group-MCT for CYP with common mental health problems. Group-MCT may aid in improving access to treatment, reduce waiting times, and improve outcomes for CYP with common mental health disorders. The study will provide important information and data to evaluate future research potential and confirm sample size estimation for a definitive large-scale RCT to test the effectiveness and cost-effectiveness of group-MCT in CYP.

Trial registration

NCT05260060; ISCTRN18335255

Cognitive Beliefs Across the Symptom Dimensions of Pediatric Obsessive-Compulsive Disorder: Type of Symptom Matters

The cognitive model of obsessive-compulsive disorder (OCD) posits that dysfunctional cognitive beliefs are crucial to the onset and maintenance of OCD; however, the relationship between these cognitive beliefs and the heterogeneity of OCD symptoms in children and adolescents remains unknown. We examined how the major belief domains of the cognitive model (inflated responsibility/threat estimation, perfectionism/intolerance of uncertainty, importance/control of thoughts) and dysfunctional metacognitions were related to OCD symptoms across the following dimensions: doubting/checking, obsessing, hoarding, washing, ordering, and neutralization. Self-report ratings from 137 treatment-seeking youth with OCD were analyzed. When cognitive beliefs and symptom dimensions were analyzed in tandem, inflated responsibility/threat estimation and dysfunctional metacognitions were uniquely related to doubting/checking, obsessing, and hoarding and perfectionism/intolerance of uncertainty to ordering. Cognitive beliefs explained a large proportion of variation in doubting/checking (61%) and obsessing (46%), but much less so in ordering (15%), hoarding (14%), neutralization (8%), and washing (3%). Similar relations between cognitive beliefs and symptom dimensions were present in children and adolescents. Cognitive beliefs appear to be relevant for pediatric OCD related to harm, responsibility, and checking, but they do not map clearly onto contamination and symmetry-related symptoms. Implications for OCD etiology and treatment are discussed.

Thinking about worry: A systematic review and meta-analysis on the assessment of metacognitions in children and adolescents

BACKGROUND

The metacognitive model of generalized anxiety disorder identifies three forms of metacognition: Positive metacognitive beliefs about worry (POS), negative metacognitive beliefs about worry (NEG), and meta-worry. Though this model was originally developed relying on adult samples, it has since been applied to children and youth in different studies, and results mostly support its validity for this group. As the roles of POS, meta-worry, and age-effects do not appear to be fully clarified for children and adolescents yet, an integration of studies on children and adolescents and the metacognitive model is both timely and worthwhile.

AIM

To summarize the current research on relationships, age-effects, and measurements for POS, NEG, and meta-worry in childhood and youth.

METHODS

We carried out a literature search in the electronic databases PsycINFO, PubMed, PSYNDEX, and ERIC in 2017 and updated in 2020. Empirical research in German or English language on metacognition was included with child and adolescent samples diagnosed with anxiety disorders or healthy controls if POS, NEG, or meta-worry were measured. Studies were included for meta-analysis if they reported correlations between these metacognitions and anxiety or worry. Consensus rating for eligibility was done for 20.89% of full-texts with 90.32% agreement. Risk of bias was assessed with the appraisal tool for cross-sectional studies and consensus rating of appraisal tool for cross-sectional studies for 20.83% of included studies attaining agreement of intraclass correlation = 0.898. Overall, correlations between metacognitions, anxiety and worry were calculated with RevMan 5.4.1, assuming random-effects models. Meta-regressions with mean age as the covariate were performed via the online tool MetaMar 2.7.0. PROSPERO-ID: CRD42018078852.

RESULTS

Overall, k = 763 records and k = 78 additional records were identified. Of those, k = 48 studies with 12839 participants were included and of those, k = 24 studies were included for meta-analysis. Most studies showed consistent NEG correlations with worry and anxiety, as well as higher values for clinical than for non-clinical samples. POS findings were less consistent. Meta-analysis revealed large effects for NEG correlating with worry and anxiety, small to medium effects for POS correlating with worry and anxiety, as well as small to medium effects for POS correlating with NEG. Meta-regressions did not reveal mean age as a significant covariate. Meta-worry was assessed in only one study. We identified eight questionnaires and one interview-format that assess metacognition about worry in children and adolescents.

CONCLUSION

POS and NEG are measurable from the age of seven upwards and correlate with anxiety and worry without influences by age. Meta-worry requires further investigation.

The moderating effect of age on the associations of cognitive and metacognitive beliefs with pediatric OCD symptoms

Although considerable research has highlighted the importance of cognitive and metacognitive beliefs in adult obsessive-compulsive disorder (OCD), there has been limited investigation of these beliefs in pediatric OCD. The present study investigated the clinical correlates of cognitive and metacognitive beliefs in pediatric OCD. Previous studies found positive relations between OCD symptoms and these beliefs in pediatric patients, and we hypothesized these beliefs would also be positively related to pediatric OCD symptom severity. We additionally hypothesized age would moderate these relationships in consideration of previous studies highlighting age differences in symptom presentation and self-reported beliefs. We also explored age differences in belief endorsements. Youth aged 7-17 (n = 142) diagnosed with OCD completed self-report scales to measure cognitive and meta-cognitive beliefs. OCD severity was assessed using self-report and clinician-rated measures. Pearson correlations, moderation analyses, and independent-samples t-tests were used to test our hypotheses and aims. Significant positive relationships were observed between cognitive and metacognitive beliefs and self-reported OCD severity, although age did not moderate these relationships. Age differences were found in belief endorsements. In conclusion, cognitive and metacognitive beliefs appear clinically relevant to pediatric OCD cases, and we recommend clinicians assess these beliefs and incorporate cognitive components to corresponding evidence-based treatment.