Embed Size (px)
Citation preview
This article was downloaded by: [West Virginia University]On: 05 November 2014, At: 15:55Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,37-41 Mortimer Street, London W1T 3JH, UK
Journal of Clinical Child & Adolescent PsychologyPublication details, including instructions for authors and subscription information:http://www.tandfonline.com/loi/hcap20
Metacognitive Beliefs and Processes in Clinical Anxietyin ChildrenKaren E. Smith a & Jennifer L. Hudson aa Department of Psychology , Macquarie UniversityPublished online: 28 Jan 2013.
To cite this article: Karen E. Smith & Jennifer L. Hudson (2013) Metacognitive Beliefs and Processes in Clinical Anxiety inChildren, Journal of Clinical Child & Adolescent Psychology, 42:5, 590-602, DOI: 10.1080/15374416.2012.755925
To link to this article: http://dx.doi.org/10.1080/15374416.2012.755925
PLEASE SCROLL DOWN FOR ARTICLE
Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) containedin the publications on our platform. However, Taylor & Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of theContent. Any opinions and views expressed in this publication are the opinions and views of the authors, andare not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon andshould be independently verified with primary sources of information. Taylor and Francis shall not be liable forany losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoeveror howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use ofthe Content.
This article may be used for research, teaching, and private study purposes. Any substantial or systematicreproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in anyform to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
Metacognitive Beliefs and Processes inClinical Anxiety in Children
Karen E. Smith and Jennifer L. Hudson
Department of Psychology, Macquarie University
Recent research has explored the role of metacognitive beliefs and processes in clinicalanxiety in youth. The aim of this study was to examine the relationship between metacog-nitions and anxiety in 7- to 12-year-old children with and without clinical anxiety disor-ders. A secondary aim of the study was to investigate the psychometric properties of therecently developed Metacognitions Questionnaire for Children (MCQ-C). The sampleconsisted of 83 children (60.2% female; Oceanian 71.1%), comprising 49 children withanxiety disorders and 34 nonclinical children. All children completed self-reportmeasures of anxiety, emotional difficulties, and metacognitions. A subsample of 7- to8-year-old participants was used to explore whether young children could whollycomprehend all items on the MCQ-C. Positive and negative metacognitive beliefs andcognitive monitoring were significantly correlated with anxiety and emotional difficult-ies. Clinical children endorsed significantly more negative and more positive metacogni-tive beliefs than nonclinical children. Each subscale of the MCQ-C had poor internalconsistency. Support for the criterion and convergent validity of the MCQ-C was found.The results suggest that certain metacognitions play a role in clinical anxiety in childrenbut that psychometrically and developmentally validated measures of these concepts inyounger individuals are needed.
Worry and fear are considered normal developmentalphenomena that are principally nonpathological innature (Gullone, 2000; Muris, Merckelbach, Gadet, &Moulaert, 2000). Various studies have concluded thatthe majority of children experience worries and fears(e.g., Muris et al., 2000), yet for a significant proportionof children, anxiety becomes pathological. Anxiety disor-ders are among the most prevalent and pervasive psycho-logical disorders of childhood and adolescence (Field &Lester, 2010; Rapee, Schniering, & Hudson, 2009).Several epidemiological studies have investigated theprevalence of anxiety disorders, with most estimatingthat at any time, between 3 and 5% of children and ado-lescents are affected by at least one anxiety disorder(Costello, Mustillo, Erkanli, Keeler, & Angold, 2003;Ford, Goodman, & Meltzer, 2003; Heiervang et al.,2007). Despite the degree of impairment and distress that
anxiety disorders cause (Gosselin et al., 2007), relativelylittle is known about why anxiety becomes pathologicalfor some children.
Although the past decade has seen an increase inresearch aimed at understanding pathological anxietyin children (Cartwright-Hatton, McNicol, & Doubleday,2006), there remains a lack of models explaining themechanisms that cause and maintain anxiety in youth(Cartwright-Hatton, 2006). Much of the research in thisarea focuses upon the relevance and downward extensionof adult models of pathological anxiety to children(Wilson, 2010). As such, the current understanding ofanxiety in youth is reliant upon models that explain anxi-ety in adult populations. Research into the mechanismsspecific to the etiology and maintenance of pathologicalanxiety in childhood is essential so that evidence-basedinterventions can be developed for this vulnerable popu-lation (Cartwright-Hatton, 2006).
In recent years, increased empirical attention hasfocused on the role of metacognitions in the developmentand maintenance of anxiety disorders. Metacognition
Correspondence should be addressed to Jennifer L. Hudson,
Centre for Emotional Health, Department of Psychology, Macquarie
University, Sydney, NSW, Australia, 2109. E-mail: jennie.hudson@
mq.edu.au
Journal of Clinical Child & Adolescent Psychology, 42(5), 590–602, 2013
Copyright # Taylor & Francis Group, LLC
ISSN: 1537-4416 print=1537-4424 online
DOI: 10.1080/15374416.2012.755925
Dow
nloa
ded
by [
Wes
t Vir
gini
a U
nive
rsity
] at
15:
55 0
5 N
ovem
ber
2014
refers to cognition about cognition and includes anyknowledge, beliefs, or strategies that are involved in theappraisal, monitoring, or control of thinking (Fisher,2009; Wells, 2000). In the adult literature, Wells (2000,2009; Wells & Matthews, 1994) has developed a meta-cognitive model of psychological disorders that hypothe-sizes that dysfunctional beliefs and perceptions about anindividual’s own cognitive processes play a central role inthe emergence and maintenance of emotional disturb-ance. Wells has proposed models specific to differentdisorders. According to the metacognitive model of gen-eralized anxiety disorder (GAD; Wells, 1995), worryingis triggered by an intrusive thought, which then activatespositive metacognitive beliefs about the usefulness ofworry, such as ‘‘If I worry I will be prepared.’’ Althoughsuch positive beliefs about worry motivate an individualto utilize worry as a coping strategy, the model suggeststhat positive metacognitive beliefs are normative and notspecific to individuals with GAD.Worry becomes patho-logical when an individual also holds negative metacog-nitive beliefs about the danger and uncontrollability ofworry, such as ‘‘Worrying could make me go crazy’’and ‘‘Worrying is uncontrollable.’’ These beliefs lead tonegative appraisals of the worry process, or worry aboutworry. Similarly, the metacognitive model of obsessive-compulsive disorder (OCD;Wells, 1997) emphasizes thaterroneous negative metacognitive beliefs about theimportance, meaning, and power of thoughts, and aboutthe need to control thoughts and perform rituals, areimportant in the maintenance of obsessive-compulsive(O-C) symptoms (Myers & Wells, 2005).
A growing body of evidence supports the linksbetween metacognitive beliefs, emotional disturbance,and anxiety disorders in adult populations (for a review,see Wells, 2009). Positive metacognitive beliefs aboutworry positively correlate with trait anxiety, worry, andO-C symptoms (Wells & Cartwright-Hatton, 2004). Inaddition, research has found that adults with anxietydisorders, nonclinical high worriers, and control parti-cipants endorse similar levels of positive metacognitivebeliefs (Cartwright-Hatton & Wells, 1997; Ruscio &Borkovec, 2004). A substantial number of studies haveidentified that negative metacognitive beliefs are posi-tively associated with proneness to pathological worryand O-C symptoms, GAD, OCD, and post-traumaticstress disorder (PTSD) symptoms (Bennett & Wells,2010; Cartwright-Hatton & Wells, 1997; Wells &Cartwright-Hatton, 2004; Wells & Papageorgiou, 1998)and can differentiate individuals with clinical anxietyfrom nonclinical controls and high worriers without dis-orders (Ruscio & Borkovec, 2004).
Considering the vast amount of research supportingthe role of metacognition in anxiety disorders in adults,the metacognitive model could potentially be applied toyounger populations (Ellis & Hudson, 2010). However,
worry in youth may not have the same features as worryin adulthood. Cognitive developmental literature sug-gests that from the age of 7, children do have the cognitivecapacity to worry (Vasey, Crnic, & Carter, 1994) but thatthe cognitive process of worry becomes more complex inmiddle childhood as the ability to predict future possibi-lities and to elaborate on multiple negative outcomesdevelops (Muris, Merckelbach, Meesters, & van denBrand, 2002). Worry becomes increasingly elaborate inadolescence due to the development of formal reasoningand abstract thinking skills (Gosselin et al., 2007; Vaseyet al., 1994).
Research in the metacognitive development field sug-gests that children’s capacity for metacognitive beliefsalso changes with age. As children develop, they areincreasingly capable of metacognitive thinking, includingattributing mental states (thoughts, beliefs, intentions,knowledge) to themselves and others, and understandingthat the beliefs and intentions of others may differ fromtheir own (Flavell, 1999). However, although children dodevelop metacognition from a young age, the metacogni-tive skills required to form beliefs about anxiety, includ-ing the awareness that thoughts are difficult to controland that one can use mental strategies to controlthoughts, tend to develop after age 5 (Flavell, Green, &Flavell, 1998, 2000). There appears to be a markedincrease in these introspective metacognitive skillsbetween the ages of 5 and 7 (Flavell et al., 2000), suggest-ing that from the age of 7 or 8 children do have thecapacity for metacognitive thoughts about anxiety.
Although the existing literature on cognitive develop-ment suggests that childrenmay have the capacity to havemetacognitive beliefs about worry and anxiety, there is alack of research investigating metacognition and anxietyin youth. Emerging research using younger populationshas attempted to confirm the associations found betweenmetacognitive beliefs and anxiety in adults. To measuremetacognition in adolescents, Cartwright-Hatton et al.(2004) developed the Meta-Cognitions Questionnaire–Adolescent Version (MCQ-A). Their study assessed therelationships between metacognitive beliefs about worryand obsessionality, anxiety, and depression in nonclinicaladolescents aged 13 to 17. They also recruited a smallclinical sample of 11 adolescents with emotional disor-ders who were age and gender matched with 11 nonclini-cal participants who had low anxiety and depressionscores. For the overall sample, Cartwright-Hatton et al.(2004) found that the MCQ-A and each of its subscaleswere significantly and positively associated with measuresof anxiety, depression, and obsessive symptoms. Inaddition, clinical participants endorsed significantly morenegative metacognitive beliefs about the danger anduncontrollability of thoughts, endorsed more negativebeliefs about the superstitious nature of thoughts, andhad higher cognitive confidence thanmatched nonclinical
METACOGNITIVE BELIEFS AND PROCESSES 591
Dow
nloa
ded
by [
Wes
t Vir
gini
a U
nive
rsity
] at
15:
55 0
5 N
ovem
ber
2014
participants. There were no group differences regardingpositive metacognitive beliefs and cognitive self-consciousness (the tendency to focus attention onthought), suggesting that clinical and nonclinical adoles-cents do not differ in their endorsement of positive beliefsabout worry or attention given to internal events.
The clinical sample in this study was small and con-sisted of adolescents with any ‘‘emotional disorder,’’and so these findings cannot be directly applied toanxiety disorders. Furthermore, the nonclinical samplewas not thoroughly screened for emotional disorders,with participants removed from the study only if theyhad sought treatment or utilized any medication, sothere is a possibility that the nonclinical sample wasnot purely nondisordered.
Ellis and Hudson (2011) extended Cartwright-Hattonet al.’s (2004) study utilizing a larger sample of 12- to17-year-old adolescents with anxiety disorders and non-clinical controls, with all participants screened forpsychological disorders using the Anxiety DisordersInterview Schedule for DSM-IV, Child and Parent ver-sions (ADIS-IV-C=P; Silverman &Albano, 1996). In con-trast to the results of Cartwright-Hatton et al. (2004),clinical participants held significantly more positive meta-cognitive beliefs than nonclinical participants. Consistentwith the findings of Cartwright-Hatton et al. (2004), thosediagnosed with anxiety disorders also held more negativemetacognitive beliefs about the danger, uncontrollabilityand superstitious nature of thoughts, and higher totalmetacognition than nonclinical adolescents. There wereno group differences regarding cognitive confidence orcognitive self-consciousness.
Metacognitions were also significantly associatedwith self-reported measures of anxiety, worry anddepression. Ellis and Hudson (2011) compared clinicallyanxious adolescents with and without a diagnosis ofGAD and found no differences on any measure of meta-cognition. These results suggest that metacognitivebeliefs may be important in a range of anxiety disordersas well as depression in youth. Last, no age differenceswere found on the MCQ-A, a finding also supportedby Cartwright-Hatton et al. (2004), which suggests thatchildren as young as 12 have the capacity for metacog-nitive beliefs. Other researchers have confirmed thatmetacognitions are associated with symptoms of anxi-ety, worry, and OCD in nonclinical adolescent samples(e.g., Mather & Cartwright-Hatton, 2004; Matthews,Reynolds, & Derisley, 2006; Wilson et al., 2011).
Only one study has specifically examined the role ofmetacognitions in the maintenance of anxiety disordersin children. Bacow, Pincus, Ehrenreich, and Brody(2009) recruited children aged 7 to 17 years, including78 clinical children who had a primary diagnosis ofGAD, OCD, social phobia or separation anxiety dis-order, and 20 nonclinical children. Bacow et al. revised
the MCQ-A (Cartwright-Hatton et al., 2004) to generatea more age-appropriate instrument that could measureself-reported metacognitions in children aged 7 andolder. The authors developed the Metacognitions Ques-tionnaire for Children (MCQ-C) by asking nine childrenaged 7 to 14 to complete the MCQ-A and report on anydifficulties. To improve the readability of the scale forchildren, the authors removed the cognitive confidencesubscale of the MCQ-A and approached clinical staffto advise item rewording. The MCQ-C has four sub-scales: Positive Meta-Worry; Negative Meta-Worry;Superstition, Punishment, and Responsibility Beliefs;and Cognitive Monitoring.
Bacow et al. (2009) found that the MCQ-C and eachof its subscales were significantly correlated with ameasure of excessive worry. After controlling for totalseverity for different content areas of worry, positivemetacognitive beliefs were no longer associated withworry. In addition, cognitive monitoring was no longerassociated with worry in the nonclinical sample. In linewith Cartwright-Hatton et al.’s (2004) research in adoles-cents, there were no significant differences between thegroups on positive metacognitive beliefs about worry.Nonclinical children scored significantly higher on cogni-tive monitoring, suggesting that children without anxietydisorders have a greater awareness of their thoughts thanchildren with pathological anxiety. This is contrary toprevious research that suggests the opposite pattern inadults (e.g., Wells & Cartwright-Hatton, 2004). Cogni-tive monitoring also increased with age, suggesting thatchildren’s capacity for this type of metacognition con-tinues to develop from childhood into adolescence.There was a lack of between-group differences in nega-tive metacognitive beliefs about the uncontrollability,dangerousness, and power of thoughts, which is also con-trary to the existing literature in adults and adolescents.In a further study utilizing the same participants, Bacow,Ehrenreich-May, Brody, and Pincus (2010) found thatclinical participants with a primary diagnosis of GAD,OCD, social phobia, or separation anxiety disorder didnot differ in their endorsement of metacognitions. Thisfinding is in line with research by Ellis and Hudson(2011) that found no differences in metacognitionsbetween different anxiety disorders. These results suggestthat investigating anxiety disorders as a whole may bejust as informative as investigating specific anxiety disor-ders when analyzing associations with metacognitions.
Bacow et al. (2009) suggested that because all parti-cipants endorsed a wide range of metacognitive beliefs,children as young as 7 may have dysfunctional beliefsabout worry. Yet several items on the MCQ-C may bedifficult for 7-year-old children to comprehend due totheir abstract nature. For example, Item 22 on the scaleis ‘‘If I couldn’t be in control of what I think, I would fallapart.’’ Considering that children tend to develop the
592 SMITH AND HUDSON
Dow
nloa
ded
by [
Wes
t Vir
gini
a U
nive
rsity
] at
15:
55 0
5 N
ovem
ber
2014
cognitive capacity for abstract thinking at around age 11(Field & Lester, 2010; Vasey et al., 1994), it is likely thatyounger individuals may have difficulty understandingthe phrase ‘‘fall apart’’ and may take it literally. Inaddition, the MCQ-C requires a participant to answeritems on a 4-point scale, ranging from 1 (do not agree)to 4 (agree very much). The nature of this scoring systemmeans that even if a child responds ‘‘do not agree’’ toevery item, he or she will still have scored above zero.Thus, before we can conclude that younger childrenendorse the full range of metacognitive beliefs, the spe-cific range of scores across the ages needs to be evaluated.
The lack of differences between the clinical and non-clinical groups in the study by Bacow and colleagues(2009) could be attributed to the nature of the nonclinicalsample. Sixty percent of the nonclinical sample had sub-clinical symptoms of anxiety and assessment of anxietydisorders for the nonclinical sample was reliant on parentreport. Considering the sample included adolescents,child report of symptoms may have been important inidentifying emotional disturbance in the nonclinical sam-ple. Last, the measure of excessive worry content used inthis study was not psychometrically validated and reliedon parent report for the nonclinical group. Despite theselimitations, the study was the first to explore the relati-onships between metacognitions and clinical anxiety inchildren. Further research is required to ensure that theMCQ-C is a valid and reliable measure of metacogni-tions in children younger than age 13.
Questions remain as to whether children have thecapacity for metacognitive beliefs about anxiety, and ifso, whether these cognitions are associated with clinicalanxiety disorders. The aim of the present study was toinvestigate the relationship between metacognitionsand anxiety in 7- to 12-year-old children with and with-out clinical anxiety disorders, using the MCQ-C. As pre-vious research suggests that children may have thecapacity to form metacognitive beliefs about anxietyfrom the age of 7 (e.g., Flavell et al., 2000), this wasthe lower age limit selected for the study. Because studieshave examined metacognition in adolescent samples(e.g., Ellis & Hudson, 2011), and the study aimed todetermine the psychometric properties of the measurein children, an upper limit of age 12 was selected.
It was hypothesized that children with anxietydisorders would score higher on a total measure of meta-cognitions about worry than children without clinicaldisorders. More specifically, it was expected that childrenwith anxiety disorders would endorse significantly morenegative metacognitive beliefs about the danger anduncontrollability of worry, and about superstition, pun-ishment, and responsibility, than nonclinical children.Based on the metacognitive model of psychological dis-orders and findings in adult populations, it was alsohypothesized that clinical children would score signifi-
cantly higher on a measure of cognitive monitoring thannonclinical children. However, it was expected that therewould be no significant difference between clinicallyanxious children and nonclinical children in the endorse-ment of positive metacognitive beliefs about worry.
A secondary aim of the study was to evaluate thepsychometric properties of the MCQ-C. More specifi-cally, the study aimed to examine the internal consistencyreliability and criterion, convergent, and discriminantvalidity of the MCQ-C. The group comparisons justdescribed will provide criterion validity of the MCQ-C.With regard to convergent validity, it was hypothesizedthat the MCQ-C would positively correlate withself-report measures of anxiety and emotional problems.With regard to discriminant validity, it was hypothesizedthat the MCQ-C would not correlate with a measure ofconduct problems. Last, the investigation aimed to quali-tatively analyze whether young children could whollycomprehend the items on the scale, by asking a sampleof younger participants (7- to 8-year-olds) to report theirunderstanding of each item.
METHOD
Participants
The sample consisted of 83 children: 49 children withanxiety disorders and 34 nonclinical children. Childrenfrom the anxious sample presented for assessment andtreatment at the Centre for Emotional Health,MacquarieUniversity. The nonclinical group consisted of childrenrecruited via an advertisement placed in a Sydney-basedparenting magazine that asked for confident children.Of the total sample, 60.2% were female, and all childrenwere between the ages of 7 and 12 (M¼ 9.18, SD¼1.56). To assess for the presence of any mental disorders,all children and parents involved in the study were inter-viewed by a clinical psychologist or psychology graduatestudent using the ADIS-IV-C=P (Silverman & Albano,1996). Diagnoses and clinical severity ratings wereassigned by each clinician and were reviewed duringsupervision with senior clinical psychologists. The pri-mary diagnoses for children in the anxious sample wereas follows: generalized anxiety disorder, 63.5%; socialphobia, 20.4%; OCD, 6.1%; specific phobia, 4.1%; separ-ation anxiety disorder, 2.0%; and posttraumatic stressdisorder, 2.0%. In addition, 89.8% of children in theanxious sample met criteria for more than one disorder.Of these children, 87.8% met criteria for more than oneanxiety disorder, 10.2% met criteria for an additionalmood disorder, 32.7% met criteria for an additional sleepdisorder, and 18.4% met criteria for an additional beha-vior disorder (attention deficit hyperactivity disorder oroppositional defiant disorder). Furthermore, one childmet criteria for a secondary diagnosis of enuresis, and
METACOGNITIVE BELIEFS AND PROCESSES 593
Dow
nloa
ded
by [
Wes
t Vir
gini
a U
nive
rsity
] at
15:
55 0
5 N
ovem
ber
2014
one child met criteria for a secondary diagnosis ofstereotypic movement disorder. The majority of childrenin the clinical sample (93.9%) were given a diagnosis ofgeneralized anxiety disorder.
Children were included in the nonclinical sample ifthey did not meet full or subclinical criteria for anypsychological disorder assessed by the ADIS-IV-C=P.Thirty-five children were recruited into the nonclinicalsample. One child was excluded due to the presence ofsubclinical anxiety symptomology. Thus, the final non-clinical sample consisted of 34 children.
Mothers reported their ethnicity as follows:Oceanian, 71.1%; Asian, 3.6%; European, 3.6%; mixedOceanian, 12.0%; and mixed European, 2.4%. Sixmothers (7.2%) did not report their ethnicity. Themajority of mothers reported a high family income, with68.7% indicating a combined family weekly income of$1,600 or more. Six mothers (7.2%) did not report theirfamily income. In terms of education, 62.2% of mothersreported having at least an undergraduate level univer-sity education.
Measures
Self-report measure of anxiety. To assess parti-cipant’s anxiety levels, the Spence Children’s AnxietyScale (SCAS; Spence, 1997) was administered. The SCASis a self-report measure that consists of 44 items, 38 ofwhich assess anxiety symptoms (and 6 filler items toreduce negative response bias). As well as an overall mea-sure of child anxiety, the SCAS provides scores on sixdistinct subscales that reflect Diagnostic and StatisticalManual of Mental Disorders (4th ed. [DSM–IV];American Psychiatric Association, 1994) childhood anxi-ety disorders: panic and agoraphobia, separation anxi-ety, physical injury fears, social phobia, generalizedanxiety disorder, and OCD. Participants were requiredto answer by circling how often each item occurs to themon a 4-point scale, ranging from 0 (never) to 3 (always).An overall anxiety score was found by summing thescores of all 38 symptom related items.
The SCAS has high internal consistency for the overallanxiety score (Muris, Schmidt, & Merckelbach, 2000;Spence, 1998; Spence, Barrett, & Turner, 2003). Inaddition, good test–retest reliability has been demon-strated both after 12 weeks (Spence et al., 2003), and 6months (Spence, 1998). The SCAS has also displayed con-vergent validity with other measures of childhood anxiety(Muris, Schmidt, et al., 2000; Spence, 1998). Spence(1998) provided evidence for the discriminant validity ofthe scale, showing that SCAS scores were significantlyhigher in clinically anxious children compared to noncli-nical children. In the current study, the SCAS demon-strated excellent internal consistency, with a total scaleCronbach’s alpha of .93. The SCAS has been successfully
administered to children from the ages of 7 to 19 (Muris,Schmidt, et al., 2000), and Australian norms for morethan 4,900 children are available (Spence, 2005), makingthe SCAS an appropriate measure of overall anxiety inthe present sample.
Self-report measure of metacognitions. Tomeasure metacognitive beliefs and thought-monitoringtendencies, the MCQ-C (Bacow et al., 2009) was admi-nistered to each participant. The MCQ-C consists of24 items divided evenly across four subscales: PositiveMeta-Worry (MCQ-C-PM); Negative Meta-Worry(MCQ-C-NM); Cognitive Monitoring (MCQ-C-CM);and Superstition, Punishment and Responsibility Beliefs(MCQ-C-SPR). Participants were asked to respond toeach item by circling how much they generally agreewith the statement on a 4-point scale, ranging from 1(do not agree) to 4 (agree very much). A total scorewas acquired by summing the scores of all items. Totalsubscale scores were obtained by adding the scores ofeach item in the particular subscale.
The MCQ-C was recently developed, and the develo-pers of the MCQ-C provided preliminary psychometricdata in their study (Bacow et al., 2009) includingadequate internal consistency for the total scale and threeof the four subscales, with coefficient alphas of 0.87 forthe total scale; 0.86 for Positive Meta-Worry; 0.75 forNegative Meta-Worry; 0.75 for Cognitive Monitoring;and 0.64 for Superstition, Punishment, and Responsi-bility Beliefs. A confirmatory factor analysis indicatedthe presence of the four factors just listed. The MCQ-Cdisplayed some concurrent validity in that it was posi-tively and significantly associated with a measure ofexcessive worry, the Penn State Worry Questionnairefor Children (Chorpita, Tracey, Brown, Collica, &Barlow, 1997). However, only the Negative Meta-Worrysubscale was significantly correlated with a measure ofdepression, the Children’s Depression Inventory(Kovacs, 1981), after the severity of worry content wascontrolled for. In Bacow et al.’s (2009) study, only onesignificant difference was found between clinicallyanxious and nonclinical children on the MCQ-C; noncli-nical children scored significantly higher than clinical chil-dren on cognitive monitoring. Thus, adequate criterionvalidity has not been demonstrated for the MCQ-C.
Parent-report and self-report measure of psycho-pathology. As a broad measure of psychopathology,and to further ensure that children in the nonclinicalsample were not experiencing emotional difficulties, eachparticipant and their mother completed the Strengthsand Difficulties Questionnaire (SDQ). The SDQ wasdeveloped by Goodman (1997) as a brief screening mea-sure of emotional and behavioral problems in children
594 SMITH AND HUDSON
Dow
nloa
ded
by [
Wes
t Vir
gini
a U
nive
rsity
] at
15:
55 0
5 N
ovem
ber
2014
and adolescents. It consists of 25 items divided evenlyacross five subscales that evaluate conduct problems,peer problems, hyperactivity-inattention, emotional dif-ficulties, and prosocial behavior. In the current study,only the self-report Emotional Difficulties (SDQ-E;e.g., somatic complaints, sadness, worry) and parent-report Conduct Problems (SDQ-C) subscales were inves-tigated. Participants are asked to mark each item as nottrue, somewhat true, or certainly true according to howthey have felt in the past 6 months.
The SDQ has adequate internal consistency.Goodman, Meltzer, and Bailey (1998) reported coef-ficient alphas of 0.75 for the Emotional Problems sub-scale and 0.72 for the Conduct Problems subscale.Satisfactory test–retest reliability after 4 to 6 monthshas also been demonstrated (Goodman, 2001). TheSDQ has shown convergent validity with other measuresof childhood psychopathology (Goodman & Scott, 1999;Klasen et al., 2000; Muris, Meesters, Eijkelenboom, &Vincken, 2004). In addition, several studies haveillustrated that the SDQ is able to discriminate betweenchildren with and without psychopathological symptoms(e.g., Goodman et al., 1998; Klasen et al., 2000). In thepresent study, the self-reported SDQ Emotional Prob-lems subscale displayed acceptable internal consistencyof .75. However, the internal consistency of the parent-reported SDQ Conduct Problems subscale was poor,with a Cronbach’s alpha of .61.
Although the SDQ was originally developed for chil-dren aged 11 to 16, it has been successfully administeredto children as young as 7 years old (Mellor, 2005). Inaddition, Mellor (2005) published norms based on asample of 900 Australian children aged 7 to 17.
Parent and child report of psychopathology. TheAnxiety Disorders Interview Schedule for DSM–IV,Child and Parent versions (ADIS-IV-C=P; Silverman &Albano, 1996) was administered to all children and par-ents involved in the study. The ADIS-IV-C=P is a semi-structured clinical interview used to diagnose mentaldisorders common in childhood, using DSM–IV criteria.For each diagnosis given, clinicians also assign a clinicalseverity rating ranging from 0 (none) to 8 (very severelydisturbing=disabling), with a clinical severity rating of 4or higher indicative of a clinical diagnosis. Research pre-viously conducted at the Centre for Emotional Healthhas shown the ADIS-IV-C=P to have excellent interraterreliability (Lyneham, Abbott, & Rapee, 2007).
Procedure
All procedures in the study received ethical approvalfrom the Macquarie University Human Ethics Commit-tee. Written informed consent was obtained from all
parents and children involved in the study. Prior toresearch participation, the parents of nonclinical childrenwere asked several questions via the telephone abouttheir child and anxiety in an attempt to include only con-fident, nonanxious children in the nonclinical sample. Alldiagnostic interviews were completed with parents andchildren on the university campus. Participants fromthe anxious sample completed the SCAS and SDQ onlinevia a secure, password-protected website, whereas non-clinical participants completed these measures on cam-pus. All children in the study completed the MCQ-C atthe university. After completing the study, nonclinicalchildren received $50 for their participation.
To assess whether young children could wholly com-prehend the items on the MCQ-C, six 7-year-old andeight 8-year-old children (seven children from each ofthe clinical=nonclinical groups) were individually askedfor feedback on each item of the MCQ-C. Dependingon the individual child, some read silently and some readaloud. After reading the question, children were asked,‘‘What do you think that means?’’ Responses were thenwritten down verbatim by the researcher. For Item 22,after an initial verbal response was given by the child,each child was asked, ‘‘What do you think fall apartmeans?’’ to further clarify whether children could fullyunderstand the item. Children were also asked to identifyany items that they did not understand. If it was clear tothe researcher that a child did not understand an item,the researcher explained the item to the child, beforethe child was asked to circle an answer. Verbatimresponses were coded by the principal researcher as eitherunderstood or misunderstood; this coding was thenreviewed by the second author. These results were ana-lyzed to assess the percentage of children that understoodeach item. Responses were qualitatively examined tonote any particular difficulties that children had withthe wording of the items.
RESULTS
Preliminary Analyses
No significant differences were found between the clini-cal and nonclinical groups with regard to age, F(1, 82)¼.30, p> .05. Chi-squared analyses showed no significantdifferences between the two groups on gender, v2(1,N¼ 83)¼ 1.32, p> .05; mother’s education, v2(5, N¼82)¼ 11.00, p> .05; mother’s ethnicity, v2(8, N¼ 77)¼11.57, p> .05; or family income, v2(8, N¼ 77)¼ 14.55,p> .05.
As shown in Table 1 clinically anxious childrenscored significantly higher than nonclinical children onmeasures of anxiety and emotional problems. Clinicalchildren scored significantly higher on the SCAS,
METACOGNITIVE BELIEFS AND PROCESSES 595
Dow
nloa
ded
by [
Wes
t Vir
gini
a U
nive
rsity
] at
15:
55 0
5 N
ovem
ber
2014
t(81)¼� 4.41, p< .001, and SDQ-E, t(81)¼� 6.50,p< .001. Clinical children also scored significantlyhigher on the SDQ-C, t(80)¼� 4.59, p< .001.
Qualitative Analysis of the MCQ-C
Comprehension of the MCQ-C items was examined in asample of fourteen 7- to 8-year-old participants (17% ofthe total sample). Information regarding the percentageof children that understood each item as well as examplesof misunderstood responses is provided in Table 2.Understanding of each item was determined if the childprovided an answer that matched the theoretical conceptunderlying each item. For example, the followingresponse clearly indicates that the child’s understandingmatched the intended meaning of the item; Item 18:‘‘Once I start worrying about something, I cannot stop,’’child’s response: ‘‘When I start worrying, I can’t stop thethoughts in my head.’’ Younger children had difficultywith abstract concepts (such as ‘‘fall apart’’ from Item22), and sometimes took phrases literally (such as ‘‘inorder’’ from Item 23). Furthermore, some of the youngerchildren were unable to read items on their own. Onechild stated, ‘‘We haven’t learnt these words yet.’’
Items were considered invalid for all 7- and 8-year-old participants if less than 70% of the qualitatively ana-lyzed sample understood the item (e.g., less than 10). Onthis basis, six items (1, 5, 6, 21, 22, 23) were consideredinvalid for all 7- and 8-year-old children. Two of these
items fell in the MCQ-C-PW subscale, three in theMCQ-C-SPR, and one in the MCQ-C-CM. For childrenaged 7 and 8, Multiple Imputation (in SPSS) was used toestimate item scores for these problematic six items.Subscale scores for the MCQ-C were computed basedon imputed values for these items. Analyses were thenconducted on multiple imputed datasets (20 data sets).
Internal Consistency Analysis
The total MCQ-C scale displayed acceptable internal con-sistency of .73 (based on the original data). The internalconsistency of each subscale of the MCQ-C was also cal-culated. The reliability of each subscale was poor, withCronbach’s alphas as follows: MCQ-C-PM a¼ .46,MCQ-C-NM a¼ .64, MCQ-C-CM a¼ .61, MCQ-C-SPR a¼ .25.1 Separate Cronbach’s alphas were computedfor clinical and nonclinical children. For the nonclinicalsample, reliability for the total MCQ-C and each of thesubscales was poor. For the clinical sample, internal con-sistency for the total MCQ-C was adequate at .76.Although the reliability of the MCQ-C-PM and MCQ-C-NM improved when only the clinical sample was con-sidered (a¼ .69 and a¼ .66, respectively), the internal con-sistency of the MCQ-C-CM and MCQ-C-SPR remainedpoor, with Cronbach’s alphas of .56 and .21, respectively.
Validity Analysis
To investigate the convergent and discriminant validityof the MCQ-C, correlations were conducted betweenthe MCQ-C, the SCAS, and the SDQ. Several variablesviolated the assumption of bivariate normality requiredfor Pearson correlations. The variables that did notmeet the assumption were MCQ-C-PM, MCQ-C-NM,MCQ-C-SPR, SCAS, SDQ-E and SDQ-C. Thus, Spear-man correlations were conducted to determine whethersignificant bivariate relationships existed between thevariables. The correlations between these measures arepresented in Table 3. Comparisons between the clinicaland nonclinical children on the MCQ-C were computedto examine the criterion validity of the scale.
Convergent validity. It was proposed that scores onthe MCQ-C would be positively correlated with mea-sures of internalizing symptoms. To examine the conver-gent validity of the MCQ-C, Spearman correlations wereconducted to determine whether significant relationshipsexisted between the MCQ-C and measures of internaliz-ing symptoms (SCAS and SDQ-E). The SCAS andSDQ-E were significantly and positively correlated withthe total MCQ-C score and three of the four MCQ-C
TABLE 1
Descriptive Statistics for Self-Report Measures
Control Clinical
Variable M SD M SD
SCAS
Total 15.00a 11.71 29.63b 16.70
SDQ
SDQ-E 1.41a 1.35 4.29b 2.32
SDQ-C 0.48a 0.83 2.00b 1.77
MCQ-C M SE M SE
Total 40.90a 0.93 46.31b 1.29
MCQ-C-PM 7.68a 0.34 9.04b 0.51
MCQ-C-NM 9.97a 0.35 12.82b 0.55
MCQ-C-SPR 10.10a 0.37 10.64a 0.37
MCQ-C-CM 13.15a 0.53 13.81a 0.46
Note. Means in the same row that do not share subscripts differ at
p< .05. SCAS¼Spence Children’s Anxiety Scale; SDQ¼ Strengths
and Difficulties Questionnaire; SDQ-E¼SDQ Emotional Problems
subscale; SDQ-C¼SDQ Conduct Problems subscale; MCQ-C¼Metacognitions Questionnaire for Children; MCQ-C-PM¼MCQ-C
Positive Meta-Worry subscale; MCQ-C-NM¼MCQ-C Negative
Meta-worry subscale; MCQ-C-SPR¼MCQ-C Superstition Punish-
ment Responsibility Beliefs subscale; MCQ-C-CM¼MCQ-C Cogni-
tive Monitoring subscale.
1Internal reliability did not improve when 7- to 8-year-old children
were excluded from the analyses.
596 SMITH AND HUDSON
Dow
nloa
ded
by [
Wes
t Vir
gini
a U
nive
rsity
] at
15:
55 0
5 N
ovem
ber
2014
subscales (MCQ-C-PM, MCQ-C-NM, MCQ-C-CM).The MCQ-C-SPR subscale was not significantly corre-lated with any measure of internalizing symptoms.Although not presented in Table 3, Spearman correla-tions were conducted to examine relationships betweenthe SCAS subscales and the MCQ-C. MCQ-C-SPRdid not significantly correlate with the Social Phobia,
Physical Injury, and O-C subscales of the SCAS.MCQ-C-CM also did not correlate with the SCAS SocialPhobia or Physical Injury subscales. The SCAS PhysicalInjury subscale was not significantly correlated with thetotal MCQ-C or MCQ-C-PM (p< .10). Otherwise allother correlations between the MCQ-C and the SCASsubscales were significant (p< .05).
TABLE 2
Percentage of MCQ-C Items Understood and Examples of Misunderstood Responses Given by a Sample of 7- to 8-Year-Old Children
Item
%
Understood Examples of Misunderstood Responses
1. If I worry about things now, I will have fewer problems in the
future
35.7 ‘‘Some people think or worry about things that are
happening in the future.’’
‘‘You won’t have as many problems in the future if you lis-
ten and concentrate.’’
2. It is not a good idea to worry because worrying is bad for me 78.5
3. I often notice the thoughts that I have in my head 71.4 ‘‘If you think of something that might happen at school, it
might happen.’’
4. If I worry a lot, I could make myself sick 85.7
5. When I am thinking about a problem in my head, I take note of
how my mind works
57.1 ‘‘When you think about a problem you might have had
during the day you could take note of the problem and
find a solution for it.’’
6. If I did not get a worry thought out of my head and then something
bad happened, it would be my fault
64.2 ‘‘Everything will be your fault if you think you worry about
stuff.’’
‘‘If you worry a lot and get it in your head, it could be your
fault and then you blame yourself.’’
7. Worrying about things helps me to be organized and keep my stuff
in order
71.4 ‘‘Worrying that your stuff won’t be in order and it helps if
you worry about it.’’
8. My worrying thoughts keep going, no matter how hard I try to put
them out of my head
92.8
9. When I am confused, worrying helps me sort things out 92.8
10. I can’t stop thinking of the things that I worry about 85.7
11. I try hard to keep track of the thoughts that I have in my head 78.5
12. I should be able to tell myself to stop and start thinking about
things whenever I want to
78.5
13. Worrying might make me go crazy 92.8
14. I am always thinking about the thoughts in my head 85.7
15. I pay a lot of attention to the way that I think 78.5
16. Worrying helps me feel better 100
17. If I can’t stop my thoughts, I am no good 71.4 ‘‘If I can’t stop thinking about thoughts in my head, and I’m
not really good at it, something like that, not good at
stopping thoughts in my head.’’
‘‘If you can’t stop your thoughts, you’re no good at trying
to stop bad thoughts and worries.’’
18. Once I start worrying about something, I cannot stop 85.7
19. If I can’t stop my thoughts, bad things will happen 78.5
20. Worrying helps me solve problems 92.8
21. It is bad to think about certain things 64.2 ‘‘It is very bad to think about things that are very certain.’’
‘‘If you think about things that might happen, it’ll make it
worse.’’
22. If I couldn’t be in control of what I think, I would fall apart 21.4 ‘‘If you weren’t in control you might think you’re going to
fall apart. Like your arm fell off, then you’d only have one
arm.’’
‘‘If you can’t control what you’re thinking, your body
would stop working.’’
23. I need to worry in order to get my work done 50 ‘‘To get work done you need to think in an order and think
about your worries in a certain way.’’
‘‘I need to worry the order of things I need to do like order
of work if I’m getting it wrong.’’
24. I think about my thoughts over and over 92.8
METACOGNITIVE BELIEFS AND PROCESSES 597
Dow
nloa
ded
by [
Wes
t Vir
gini
a U
nive
rsity
] at
15:
55 0
5 N
ovem
ber
2014
Discriminant validity. It was hypothesized thatscores on the MCQ-C would not significantly correlatewith scores on the SDQ-C. To examine the discriminantvalidity of the MCQ-C, correlations between the scaleand a parent reported measure of externalizing symp-toms (SDQ-C) were conducted. The hypothesis wasmet; there were no significant correlations between theSDQ-C and the MCQ-C and each of its subscales.
Criterion validity. Table 1 shows the descriptivestatistics and between-group differences on the MCQ-C.As hypothesized, clinical children scored significantlyhigher than nonclinical children on the total MCQ-C,t(81)¼� 3.12, p¼ .002, indicating that clinically anxiouschildren endorsed more metacognitive beliefs than chil-dren without an anxiety disorder. As expected, clinicalchildren also endorsed significantly more negativebeliefs about worry than nonclinical children, as mea-sured by the MCQ-C-NM, t(81)¼� 3.94, p< .001. Con-trary to our hypothesis, there was a significant differencebetween anxious and nonanxious children on MCQ-C-PM, with clinically anxious children endorsing signifi-cantly more positive beliefs about worry, t(81)¼ 2.042,p< .05. There were no significant differences betweengroups found on the MCQ-C subscales measuringsuperstition, punishment and responsibility beliefs andcognitive monitoring2 (ps> .05).
DISCUSSION
This study aimed to investigate the relationshipsbetween metacognitions and anxiety in children aged 7to 12 with and without clinical anxiety disorders. Asecondary purpose of the current investigation was to
examine the psychometric properties of the MCQ-Cand to ascertain whether the scale is an age appropriatemeasure of metacognition in younger children. Asanticipated, children with anxiety disorders reported sig-nificantly more metacognitions than those without clini-cal diagnoses, as measured by the total MCQ-C score.When individual subscales were analyzed, clinicalchildren endorsed more negative metacognitive beliefsabout worry than nonclinical children. These resultsare consistent with the hypothesis and with research inadolescent populations (Cartwright-Hatton et al.,2004; Ellis & Hudson, 2011). This is the first study toprovide evidence for the role of negative metacognitivebeliefs in anxiety disorders in children. Moreover, thefinding that across all participants, negative metacogni-tive beliefs were significantly correlated with anxiety andemotional difficulties, further highlights that thesebeliefs are associated with anxiety in youth. Contraryto our hypothesis, there was a significant differencebetween participants with and without anxiety on ameasure of positive metacognitive beliefs about worry.Although this conflicts with previous research in chil-dren with clinical anxiety (Bacow et al., 2009), it is con-sistent with the findings from Ellis and Hudson (2011).Ellis and Hudson showed that adolescents with anxietyreported more positive beliefs about their worry thannonclinical adolescents. Like the current study, clinicalparticipants were more likely to report that worryingwould lead to a positive result (e.g., solve problems, bemore organized). These results are supported by the cor-relational findings that positive beliefs were positivelyassociated with anxiety symptoms and emotional diffi-culties. Cartwright-Hatton et al. (2004) also found thispattern of results in their sample of adolescents. Accord-ing to the metacognitive model of GAD (Wells, 1995),positive metacognitive beliefs support the use of worryas a coping strategy, and lead to the use of ‘‘Type 1worry,’’ which consists of contemplation of a range of
TABLE 3
Correlations (Pooled Data) Between the MCQ-C and the SCAS and SDQ for the Entire Sample
Variable 1 2 3 4 5 6 7 8
1.MCQ-C —
2.MCQ-C-PM .57�� —
3.MCQ-C-NM .79�� .36�� —
4.MCQ-C-SPR .62�� .12 .38�� —
5.MCQ-C-CM .68�� .22y
.35�� .37�� —
6.SCAS .46�� .30�� .47�� .19y
.27� —
7.SDQ-E .45�� .28� .48�� .18 .21y
.73�� —
8.SDQ-C .08 .14 .06 .01 .02 .41�� .40�� —
Note. SCAS¼ Spence Children’s Anxiety Scale; SDQ¼Strengths and Difficulties Questionnaire; SDQ-E¼ SDQ Emotional
Problems subscale; SDQ-C¼SDQ Conduct Problems subscale; MCQ-C¼Metacognitions Questionnaire for Children; MCQ-C-
PM¼MCQ-C Positive Meta-Worry subscale; MCQ-C-NM¼MCQ-C Negative Meta-Worry subscale; MCQ-C-SPR¼MCQ-C
Superstition Punishment Responsibility Beliefs subscale; MCQ-C-CM¼MCQ-C Cognitive Monitoring subscale.yp< .10. �p< .05. ��p< .01.
2A second analysis was conducted comparing children with a diag-
nosis of GAD to nonclinical children. The results were unchanged.
598 SMITH AND HUDSON
Dow
nloa
ded
by [
Wes
t Vir
gini
a U
nive
rsity
] at
15:
55 0
5 N
ovem
ber
2014
negative outcomes and how to cope with them (Wells,2006). Type 1 worrying is associated with changes inemotion, especially anxiety. However, this type of worryis not pathological; worry becomes pathological whenan individual also holds negative metacognitive beliefsabout worry. The results of the present study are onlypartially consistent with the predictions of this model,and thus this study provides preliminary evidence forthe application of metacognitive models to anxiety dis-orders in childhood. Furthermore, the results provideevidence that the MCQ-C can differentiate betweenclinical and nonclinical children based on negative andpositive metacognitive beliefs, and thus support the cri-terion validity of the scale.
Contrary to expectations, clinically anxious andnonclinical children endorsed a similar number of super-stition, punishment and responsibility beliefs. Further-more, these metacognitive beliefs were not correlatedwith anxiety or emotional symptoms. Although Bacowet al. (2009) found no differences between groups on thismeasure, investigations in older populations have foundthat anxious adolescents endorse a greater number ofthese beliefs (Cartwright-Hatton et al., 2004; Ellis &Hudson, 2011). Considering various studies in olderpopulations have found these metacognitive beliefs arelinked to anxiety disorders in adults and adolescents, itis possible that the capacity to hold superstition, punish-ment, and responsibility beliefs does not develop untiladolescence. These types of beliefs are quite abstractand involve processing future possibilities. Abstractreasoning skills may not develop until adolescence(Vasey et al., 1994), and thus the lack of group differ-ences found in the current study could be due to a lackof cognitive capacity to have such beliefs, rather thandue to similarity across groups.
According to Wells (1997), superstition, punishment,and responsibility beliefs are particularly important inthe development and maintenance of OCD. The simi-larity across groups in this study could be due to thesmall number of clinical children with a primary diag-nosis of OCD (6.1%). In fact, only 20.4% of the clinicalsample had a diagnosis of OCD. At this percentage,any differences between clinical and nonclinical childrenon superstition, punishment, and responsibility beliefsare unlikely to be found. If a clinical sample of childrenwith purely primary OCD were utilized, perhaps differ-ences between clinical and nonclinical children wouldresult. Another possibility is that the MCQ-C subscalemeasuring superstition, punishment, and responsibilitybeliefs is not a valid measure of this type of metacogni-tion in children. Half of the items on this subscale werenot understood by a sample of the 7- and 8-year-old chil-dren in the study, and its internal consistency was verypoor. It must be noted that the interpretation of thesefindings are limited by the poor internal consistency of
the subscale measuring superstition, punishment, andresponsibility beliefs. It is possible that the subscalewas not able to reliably identify the presence of suchbeliefs in the sample, which may explain the lack of dif-ferences found between clinical and nonclinical children.
As expected, cognitive monitoring was positively asso-ciated with anxiety and emotional symptoms. However,children with and without anxiety reported a similar levelof cognitive monitoring. This was an unexpected result.The metacognitive model of psychological disorders(Wells, 2000) hypothesizes that those with clinical disor-ders hold an attentional bias toward threatening cog-nition. The current research does not support this notionfor children, at least in the form of a heightened awarenessof thoughts in general. Although contrary to expectations,this result is in line with previous research comparingclinically anxious and nonclinical adolescents on cognitiveself-consciousness, that is, cognitive monitoring(Cartwright-Hatton et al., 2004; Ellis & Hudson, 2011).However, this result differs from research that has foundnonclinical children monitor their thoughts more closelythan children with anxiety (Bacow et al., 2009).
There are a few potential explanations for the lack ofdifferences in cognitive monitoring between groups. It ispossible that children do not have the cognitive capacityto report on their own monitoring of their thoughts.Bacow et al. (2009) found that cognitive monitoringscores increased with age, and Flavell et al. (2000) foundthat with increasing age, children were better able tomonitor and retrospectively report on their thoughts.This suggests that this specific metacognitive abilitymay not be fully formed in childhood and, thus, maynot be important in the etiology or maintenance ofchildhood anxiety disorders. In addition, the CognitiveMonitoring subscale of the MCQ-C does not specificallyaim to assess for anxious, intrusive, or repetitivethoughts. Thus, it may not be an appropriate measureto test the hypothesis of the metacognitive model thatanxious individuals hold an attentional bias to threat.Last, the internal consistency of the Cognitive Monitor-ing subscale was poor. Consequently, any interpretationof these findings must be considered with caution.
Taken together, the group comparison results suggestthat whilst certain aspects of the metacognitive modelsproposed by Wells (1995, 1997, 2000) are relevant toclinically anxious children, other elements of the modelmay not be supported in this population. Negativebeliefs about the uncontrollability and danger ofthoughts may play a role in the development and main-tenance of anxiety disorders in childhood. Across thesample, with the exception of superstition, punishment,and responsibility beliefs, metacognitions were posi-tively associated with anxiety symptoms and emotionalproblems. This suggests that regardless of clinical status,children with higher self-reported emotional difficulties
METACOGNITIVE BELIEFS AND PROCESSES 599
Dow
nloa
ded
by [
Wes
t Vir
gini
a U
nive
rsity
] at
15:
55 0
5 N
ovem
ber
2014
tend to endorse more metacognitive beliefs and monitortheir thoughts more closely than those with lowerself-reported difficulties. This is consistent with pastresearch in both adolescent and child populations show-ing that metacognitive beliefs and processes are signifi-cantly associated with measures of anxiety(Cartwright-Hatton et al., 2004; Ellis & Hudson,2011), O-C symptoms (Mather & Cartwright-Hatton,2004; Matthews et al., 2006), and worry (Bacow et al.,2009; Ellis & Hudson, 2011; Wilson et al., 2011). How-ever, the lack of differences between clinical and noncli-nical children on superstition, punishment, andresponsibility beliefs, and cognitive monitoring suggeststhat these factors are not associated with clinical presen-tations of anxiety. This may be because children do notyet hold the capacity for these metacognitions, becausethe MCQ-C is not a valid measure of these constructsin children, or because they are simply not relevant inchildhood disorders. These results highlight that devel-opmental considerations must be taken into accountwhen applying adult models of anxiety to younger popu-lations.
As metacognitions were significantly correlated withanxiety, these results do provide evidence for the conver-gent validity of the MCQ-C. Clinical children scored sig-nificantly higher on parent-reported conduct problems,yet the SDQ-C was not associated with the MCQ-C.This provides strong evidence for the discriminant val-idity of the MCQ-C. However, the internal consistencyof the SDQ-C was poor, so this result should be inter-preted with caution.
The study does provide support for the validity of theMCQ-C; however, analyses did not confirm the internalconsistency reliability of the scale. Although the internalconsistency of the total scale is acceptable, each of thefour subscales of the MCQ-C failed to achieve adequateinternal consistency and the alpha for the nonclinicalsample was poor. These results were inconsistent withthose of Bacow et al. (2009), who found adequate inter-nal consistency reliability for the total MCQ-C andthree of the four subscales. The subscale measuringsuperstition, punishment, and responsibility beliefs hadpoor internal reliability in both studies.
The qualitative analysis of the MCQ-C found that asample of children aged 7 and 8 were not able to whollycomprehend all items on the scale. There were six itemsacross three of the four subscales that were understoodby less than 70% of the subsample. Younger childrenmisunderstood abstract concepts (e.g., ‘‘fall apart’’ fromItem 22, and ‘‘no good’’ from Item 17), had difficultyconceptualizing future-oriented items (e.g., ‘‘if . . . then. . .’’ statements from Items 1, 6, and 22), and tookphrases literally (e.g., ‘‘take note’’ from Item 5, ‘‘certainthings’’ from Item 21, and ‘‘in order’’ from Item 23). Inaddition, some children were unable to read the items on
their own and requested help from the examiner.Although only a small subsample was used, these quali-tative results provide preliminary information that sug-gests that the MCQ-C may not be appropriate for usein younger children aged 7 and 8. If the MCQ-C is goingto be used in younger children, further development ofthese items must occur. With simple rewording, thecomprehension of some items would improve. Forexample, changing ‘‘certain things’’ to ‘‘some things’’(Item 21) would simplify the item. Also, the scale usesthe phrase ‘‘in order’’ twice, once in a literal way (Item7) and once in an abstract way (Item 23). Removing‘‘in order’’ in Item 23 would reduce children’s confusionof the items. Item 23 could instead be ‘‘I need to worryto get my work done.’’ Further research should investi-gate whether a larger sample of children are able to com-prehend each item. Without a valid measure ofmetacognition in younger children, it cannot be con-cluded that children have the capacity for metacognitivethinking about anxiety.
Because of the questionable internal consistency ofthe subscales of the MCQ-C, the results of this studymust be considered with caution. Future research shouldconduct a confirmatory factor analysis with a largersample of children in order to further analyze the struc-ture and internal consistency of the MCQ-C. Inaddition, the evidence for the discriminant validity ofthe MCQ-C is based upon the correlation of a subscalewith poor internal consistency (the SDQ-C). Theseresults should be replicated with a larger sample to con-firm the validity of the MCQ-C. Another methodologi-cal limitation is the absence of a measure of Type 1worry. A measure of Type 1 worry is not currently avail-able for children and as such Type 1 worry was not con-trolled for in the current study. Wells and Carter (1999)showed that metacognitive worry was predictive ofpathological worry independently of Type 1 worry.Thus future research needs to develop a measure thatseparates Type 1 and Type 2 worry for this purpose.
A further limitation of this study is its cross-sectionalnature. As such, it is not possible to ascertain whethermetacognitions about worry lead to anxiety, or whethermaladaptive metacognitive beliefs are the result of aclinical disorder. Preliminary research in nonclinicaladults has identified beliefs about the uncontrollabilityand danger of thoughts as a significantly positive predic-tor of anxiety (Yilmaz, Gencoz, & Wells, 2011). At thisstage, there is a lack of evidence supporting the impliedpremise that dysfunctional metacognitions lead to clini-cal anxiety in youth, as theorized by metacognitive mod-els. To confirm causality, longitudinal research thatfollows children with and without anxiety disorders overtime, or research that manipulates metacognitive beliefs,is needed. Longitudinal or experimental designs couldhelp to confirm the direction of the relationship between
600 SMITH AND HUDSON
Dow
nloa
ded
by [
Wes
t Vir
gini
a U
nive
rsity
] at
15:
55 0
5 N
ovem
ber
2014
metacognitive thinking and clinical disorders. Althoughsome ethnic and socioeconomic diversity was present inthe sample, it was a predominately a White, middle-classsample, and therefore results should not be generalizedbeyond this. Finally, additional investigations withlarger sample sizes examining metacognitive beliefs inchildren with different anxiety disorders, particularlyGAD and OCD, would help to ascertain any differencesthat may exist in the development and maintenance ofdifferent disorders.
Results from this study have important implicationsfor the conceptualization of pathological anxiety in chil-dren. Negative and positive metacognitive beliefs aboutworry may be involved in the development and mainte-nance of clinical anxiety in children. This has importantimplications in terms of treatment for children with clini-cally significant worry. Clinicians need to consider thechild’s metacognitive worry and target negative andpositive beliefs about worry. Further research is nowrequired to replicate these findings in larger clinical sam-ples. In addition, children may not hold the cognitivecapacity to have certain metacognitive beliefs and pro-cesses. At this stage, it is difficult to confirm whether chil-dren lack the metacognitive capacity to have particularbeliefs about anxiety, or whether currently developedself-report instruments are inadequate measures of thisform of cognition in children. Regardless, this studyprovides evidence supporting the role of metacognitivebeliefs in clinical anxiety disorders in children.
REFERENCES
American Psychiatric Association. (1994). Diagnostic and statistical
manual of mental disorders (4th ed.). Washington, DC: Author.
Bacow, T. L., Ehrenreich-May, J., Brody, L. R., & Pincus, D. B.
(2010). Are there specific metacognitive processes associated
with anxiety disorders in youth? Psychology Research and Behavior
Management, 3, 81–90.
Bacow, T. L., Pincus, D. B., Ehrenreich, J. T., & Brody, L. R. (2009).
The metacognitions questionnaire for children: Development and
validation in a clinical sample of children and adolescents with anxi-
ety disorders. Journal of Anxiety Disorders, 23, 727–736.
Bennett, H., & Wells, A. (2010). Metacognition, memory disorganiza-
tion and rumination in posttraumatic stress symptoms. Journal of
Anxiety Disorders, 24, 318–325.
Cartwright-Hatton, S. (2006). Anxiety of childhood and adolescence:
Challenges and opportunities.Clinical Psychology Review, 26, 813–816.
Cartwright-Hatton, S., Mather, A., Illingworth, V., Brocki, J.,
Harrington, R., & Wells, A. (2004). Development and preliminary
validation of the Meta-Cognitions Questionnaire–Adolescent
Version. Anxiety Disorders, 18, 411–422.
Cartwright-Hatton, S., McNicol, K., & Doubleday, E. (2006). Anxiety
in a neglected population: Prevalence of anxiety disorders in
pre-adolescent children. Clinical Psychology Review, 26, 817–833.
Cartwright-Hatton, S., & Wells, A. (1997). Beliefs about worry and
intrusions: The Meta-Cognitions Questionnaire and its correlates.
Journal of Anxiety Disorders, 11, 279–296.
Chorpita, B. F., Tracey, S. A., Brown, T. A., Collica, T. J., & Barlow,
D. H. (1997). Assessment of worry in children and adolescents: An
adaptation of the Penn State Worry Questionnaire. Behaviour
Research and Therapy, 35, 569–581.
Costello, E. J., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A.
(2003). Prevalence and development of psychiatric disorders in
childhood and adolescence. Archives of General Psychiatry, 60,
837–844.
Ellis, D. M., & Hudson, J. L. (2010). The metacognitive model of
generalized anxiety disorder in children and adolescents. Clinical
Child and Family Psychology Review, 13, 151–163.
Ellis, D. M., & Hudson, J. L. (2011). Test of the metacognitive model
of Generalized Anxiety Disorder in anxiety-disordered adolescents.
Journal of Experimental Psychopathology, 2, 28–43.
Field, A. P., & Lester, K. J. (2010). Is there room for ‘development’ in
developmental models of information processing biases to threat in
children and adolescents? Clinical Child and Family Psychology
Review, 13, 315–332.
Fisher, P. L. (2009). Obsessive compulsive disorder: a comparison
of CBT and the metacognitive approach. International Journal of
Cognitive Therapy, 2, 107–122.
Flavell, J. H. (1999). Cognitive development: Children’s knowledge
about the mind. Annual Review of Psychology, 50, 21–45.
Flavell, J. H., Green, F. L., & Flavell, E. R. (1998). The mind has a
mind of its own: Developing knowledge about mental uncontroll-
ability. Cognitive Development, 13, 127–138.
Flavell, J. H., Green, F. L., & Flavell, E. R. (2000). Development of
children’s awareness of their own thoughts. Journal of Cognition
and Development, 1, 97–112.
Ford, T., Goodman, R., & Meltzer, H. (2003). British child and
adolescent mental health survey 1999: The prevalence of DSM–IV
disorders. Journal of the American Academy of Child and Adolescent
Psychiatry, 42, 1203–1211.
Goodman, R. (1997). The Strengths and Difficulties Questionnaire:
A research note. Journal of Child Psychology and Psychiatry, 38,
581–586.
Goodman, R. (2001). Psychometric properties of the Strengths and
Difficulties Questionnaire. Journal of the American Academy of Child
and Adolescent Psychiatry, 40, 1337–1345.
Goodman, R., Meltzer, H., & Bailey, V. (1998). The Strengths and Dif-
ficulties Questionnaire: A pilot study on the validity of the self-report
version. European Child and Adolescent Psychiatry, 7, 125–130.
Goodman, R., & Scott, S. (1999). Comparing the Strengths and
Difficulties Questionnaire and the Child Behavior Checklist: Is small
beautiful? Journal of Abnormal Child Psychology, 27, 17–24.
Gosselin, P., Langlois, F., Freeston, M. H., Ladouceur, R., Laberge,
M., & Lemay, D. (2007). Cognitive variables related to worry among
adolescents: Avoidance strategies and faulty beliefs about worry.
Behaviour Research and Therapy, 45, 225–233.
Gullone, E. (2000). The development of normal fear: A century of
research. Clinical Psychology Review, 20, 429–451.
Heiervang, E., Stormark, K. M., Lundervold, A. J., Heimann, M.,
Goodman, R., Posserud, M., et al (2007). Psychiatric disorders in
Norwegian 8- to 10-year-olds: An epidemiological survey of preva-
lence, risk factors, and service use. Journal of the American Academy
of Child and Adolescent Psychiatry, 46, 438–447.
Klasen, H., Woerner, W., Wolke, D., Meyer, R., Overmeyer, S.,
Kaschnitz, W., et al (2000). Comparing the German versions of
the Strengths and Difficulties Questionnaire (SDQ–Deu) and
the Child Behavior Checklist. European Child and Adolescent Psy-
chiatry, 9, 271–276.
Kovacs, M. (1981). Rating scales to assess depression in school-aged
children. Acta Paedopsychiatrica, 46, 305–315.
Lyneham, H. J., Abbott, M. J., & Rapee, R. M. (2007). Interrater
reliability of the Anxiety Disorders Interview Schedule for DSM–IV
METACOGNITIVE BELIEFS AND PROCESSES 601
Dow
nloa
ded
by [
Wes
t Vir
gini
a U
nive
rsity
] at
15:
55 0
5 N
ovem
ber
2014
Child and Parent Version. Journal of the American Academy of Child
& Adolescent Psychiatry, 46, 731–736.
Mather, A., & Cartwright-Hatton, S. (2004). Cognitive predictors of
obsessive-compulsive symptoms in adolescence: A preliminary
investigation. Journal of Clinical Child and Adolescent Psychology,
33, 743–749.
Matthews, L., Reynolds, S., & Derisley, J. (2006). Examining cognitive
models of obsessive compulsive disorder in adolescents. Behavioural
and Cognitive Psychotherapy, 35, 149–163.
Mellor, D. (2005). Normative data for the Strengths and Difficulties
Questionnaire in Australia. Australian Psychologist, 40, 215–222.
Muris, P., Meesters, C., Eijkelenboom, A., & Vincken, M. (2004).
The self-report version of the Strengths and Difficulties Question-
naire: Its psychometric properties in 8- to 13- year-old non-
clinical children. British Journal of Clinical Psychology, 43,
437–448.
Muris, P., Merckelbach, H., Gadet, B., & Moulaert, V. (2000). Fears,
worries, and scary dreams in 4- to 12-year-old children: Their
content, developmental pattern, and origins. Journal of Clinical
Child Psychology, 29, 43–52.
Muris, P., Merckelbach, H., Meesters, C., & van den Brand, K. (2002).
Cognitive development and worry in normal children. Cognitive
Therapy and Research, 26, 775–787.
Muris, P., Schmidt, H., & Merckelbach, H. (2000). Correlations
among two self-report questionnaires for measuring DSM-defined
anxiety disorder symptoms in children: The Screen for Child
Anxiety Related Emotional Disorders and the Spence Children’s
Anxiety Scale. Personality and Individual Differences, 28, 333–346.
Myers, S. G., & Wells, A. (2005). Obsessive-compulsive symptoms:
The contribution of metacognitions and responsibility. Anxiety
Disorders, 19, 806–817.
Rapee, R. M., Schniering, C. A., & Hudson, J. L. (2009). Anxiety dis-
orders during childhood and adolescence: Origins and treatment.
Annual Review of Clinical Psychology, 5, 311–341.
Ruscio, A. M., & Borkovec, T. D. (2004). Experience and appraisal of
worry among high worriers with and without generalized anxiety
disorder. Behaviour Research and Therapy, 42, 1469–1482.
Silverman, W. K., & Albano, A. M. (1996). The Anxiety Disorders
Interview Schedule for Children for DSM–IV: (Child and Parent
Versions). San Antonio, TX: Psychological Corporation.
Spence, S. H. (1997). Structure of anxiety symptoms among children:
A confirmatory factor-analytic study. Journal of Abnormal
Psychology, 106, 280–297.
Spence, S. H. (1998). A measure of anxiety symptoms among children.
Behaviour Research and Therapy, 36, 545–566.
Spence, S. H. (2005). [Australian normative data for the Spence
Children’s Anxiety Scale]. Unpublished raw data.
Spence, S. H., Barrett, P. M., & Turner, C. M. (2003). Psychometric
properties of the Spence Children’s Anxiety Scale with young
adolescents. Anxiety Disorders, 17, 605–625.
Vasey, M. W., Crnic, K. A., & Carter, W. G. (1994). Worry in
childhood: A developmental perspective. Cognitive Therapy and
Research, 18, 529–549.
Wells, A. (1995). Meta-cognition and worry: A cognitive model of gen-
eralized anxiety disorder. Behavioural and Cognitive Psychotherapy,
23, 301–320.
Wells, A. (1997). Cognitive therapy of anxiety disorders: A practice
manual and conceptual guide. Chichester, UK: Wiley.
Wells, A. (2000). Emotional disorders and metacognition: Innovative
cognitive therapy. Chichester, England: Wiley.
Wells, A. (2006). The metacognitive model of worry and generalised
anxiety disorder. In G. C. L Davey & A. Wells (Eds.), Worry and
its psychological disorders: Theory, assessment and treatment
(pp. 179–199). Chichester, England: Wiley.
Wells, A. (2009). Metacognitive therapy for anxiety and depression.
New York, NY: Guilford.
Wells, A., & Carter, K. (1999). Preliminary tests of a cognitive model
of generalized anxiety disorder. Behaviour Research and Therapy, 37,
585–594.
Wells, A., & Cartwright-Hatton, S. (2004). A short form of the meta-
cognitions questionnaire: properties of the MCQ–30. Behaviour
Research and Therapy, 42, 385–396.
Wells, A., & Matthews, G. (1994). Attention and emotion: A clinical
perspective. Hove, UK: Erlbaum.
Wells, A., & Papageorgiou, C. (1998). Relationships between worry,
obsessive-compulsive symptoms and meta-cognitive beliefs. Behav-
iour Research and Therapy, 36, 899–913.
Wilson, C. (2010). Pathological worry in children: What is currently
known? Journal of Experimental Psychology, 1, 6–33.
Wilson, C., Budd, B., Chernin, R., King, H., Leddy, A., Maclennan,
F., et al (2011). The role of meta-cognition and parenting in
adolescent worry. Journal of Anxiety Disorders, 25, 71–79.
Yilmaz, A. E., Gencoz, T., & Wells, A. (2011). The temporal
precedence of metacognition in the development of anxiety and
depression symptoms in the context of life-stress: A prospective
study. Journal of Anxiety Disorders, 25, 389–396.
602 SMITH AND HUDSON
Dow
nloa
ded
by [
Wes
t Vir
gini
a U
nive
rsity
] at
15:
55 0
5 N
ovem
ber
2014
