Metacognitive Awareness And Executive Function İn Attention Deficit/Hyperactivity Disorder
Abstract
Background: A pilot study was performed to examine
the relationship between metacognitive awareness and
executive functions in children with attention deficit/
hyperactivity disorder (ADHD).
Methods: Children who were diagnosed with ADHD and
were treatment naïve were consecutively included in
the study. The Wechsler Intelligence Scale for Children-
Revised (WISC-R) and the Metacognitive Awareness
Inventory for Children (Jr. MAI)-A and B forms were used.
The participants’ teachers and parents completed the
Behavioral Rating Inventory of Executive Function (BRIEF)
and Conners’ Rating Scale (CRS) forms.
Results: This study included 45 children with ADHD (51.1%
boys) with a mean age of 9.7±2.2 years. While the BRIEFparent-
initiate scores were positively correlated with
the WISC-R-total scores (r=0.315, p=0.040), they were
negatively correlated with the Jr.-MAI scores (r=-0.378,
p=0.011). No correlation was found between the Conners’
and Jr.-MAI scores. A positive correlation was found
between the Conners’-parent and the BRIEF-parentemotional
control (r=0.324, p=0.030) and BRIEF-parentinitiate
(r=0.422, p=0.004) scores. There were positive
correlations between the Conners’-teacher and all BRIEFteacher-
sub-domains.
Conclusion: Metacognitive awareness and executive
functions and intelligence level and executive functions
were not correlated in children with ADHD.
Introduction
Attention deficit/hyperactivity disorder (ADHD) is one
of the most frequently diagnosed neurodevelopmental
disorders during childhood and adolescence, with a
prevalence rate of 5% in children 4–17 years old (1).
ADHD is characterized by symptoms of inattention,
hyperactivity, and impulsivity at a frequency and intensity
inappropriate for the individual’s age and level of
development. ADHD does not involve a simple deficit
in attention; the symptoms have been associated with
deficits in executive function (EF). Several authors have
proposed that the symptoms of ADHD arise from a
primary deficit in a specific EF domain such as response
inhibition, working memory or a more general weakness
in executive control (2-7).
Metacognition is defined as an individual’s knowledge
of his/her cognitive processes and the ability to regulate
his/her own cognitive processes using this knowledge and
express the operations he/she uses to be aware of, monitor,
control, and regulate his/her cognitive processes (8, 9).
The cognitive processes that are monitored and regulated
include learning, problem solving, comprehension, reasoning,
and memory (9, 10). Children with ADHD often
have difficulties with inhibitory control and frequently
fail to manage or control their behavioral responses (11),
and in school, these children have difficulty maintaining
on-task behaviors or following through when given
instructions, producing work of poorer quality than they
are capable of (12, 13). A neurobiological dysfunction
involving regions of the prefrontal cortex associated with
behavioral inhibition is combined with the executive
dysfunctions in ADHD, especially regarding the multidimensional
EF system controlling higher-order cognitive
processes implemented by an executive prefrontal control
Metacognitive Awareness and Executive Function
in Attention Deficit/Hyperactivity Disorder
Melek Gözde Luş, MD,1 and Habib Erensoy, MD2
1 Haydarpaşa Numune Training and Research Hospital, Department of Child and Adolescent Psychiatry, University of Health Sciences,
Istanbul, Turkey
2 Psychiatry Department, Uskudar University, Istanbul, Turkey
43
Melek Gözde Luş and Habib Erensoy
network that interacts with the cortical and subcortical
affective networks (14, 15). The conceptual link between
behavioral inhibition, EF, and metacognition has led to
the hypothesis that children with ADHD may experience
difficulties in metacognition and, thus, that measures of
EF, especially behavioral inhibition and metacognition,
should be positively correlated. Because children with
ADHD encounter numerous psychosocial and occupational
challenges as they grow up, it is particularly
important for intervention efforts to understand EF,
metacognition, and how they relate to each other. Some
authors have reported that metacognitive interventions
for attention produce encouraging results with children
with ADHD, although the research is still limited (16).
There is continued interest in the research and clinical
utility of EF measures, including both neuropsychological
and behavioral ratings. The most frequently used rating
scale for EF is the Behavior Rating Inventory of Executive
Function (BRIEF) (17). Gioia et al. (17) used the standardized
parent and teacher report forms of the BRIEF
and reported that children with ADHD had significantly
higher scores on virtually all of the scales than the comparison
controls. Based on this knowledge, we aimed to
examine the relationship between metacognitive awareness
and executive functions in children with ADHD.
Our hypothesis is that children with ADHD will have
lower scores on learning behaviors and have lower academic
achievements. The second objective was to analyze the
relationships among EF, metacognitive awareness, and
symptoms of inattention and hyperactivity/impulsivity, and
identify which aspects of EF and/or ADHD symptoms have
greater relevance for metacognition in children with ADHD.
Our goal is that our study will aid in developing methods
to help students with ADHD achieve academic success
and lead to more effective intervention strategies.
Methods
Patients
All children who visited the Department of Child and
Adolescent Psychiatry in our hospital over a six-month
period and were diagnosed with ADHD were consecutively
included in the study. Children were diagnosed as having
ADHD according to a structured clinical interview based
on the criteria defined by the Diagnostic and Statistical
Manual of Mental Disorders-5th edition (DSM-5) (18).
The children with ADHD were included in the study on
condition that they were treatment naïve. The exclusion
criteria were the presence of a chronic medical illness, any
sensory-motor disability, neurological disorder, diagnosis
of autistic spectrum disorder, and other developmental
disorders. The entire initial number of children admitted
to our hospital during these six months was about 300.
However, 55 children with ADHD had severe comorbidities
such as major depression, mania, and bipolar disorder and
were excluded; 60 children with ADHD were taking medications
previously (31 children on methylphenidate and 29
children on atomoxetine) and were excluded. Ninety-five
of the children with ADHD did not agree to participate in
the study and 45 children with ADHD had chronic medical
illnesses. Children with any sensory-motor disability or
neurological disorder were excluded. Finally, 45 children
who were eligible to enter the study were selected.
Procedure
A clinician administered the Wechsler Intelligence Scale
for Children-Revised (WISC-R) and the Metacognitive
Awareness Inventory for Children (Jr. MAI)-A and B
forms. The participants’ teachers and parents completed
the Behavioral Rating Inventory of Executive Function
(BRIEF) and the Conners’ Rating Scale (CRS) forms. The
parents’ forms were completed by both the mother and
father. The teacher form was completed by the teacher of
each participant’s class.
Assessments
The Metacognitive Awareness Inventory for Children (Jr.
MAI) was developed by Sperling et al. (19) for children
and based on the MAI developed by Schraw and Dennison
(20) for adults. The MAI consists of 52 items; for the Jr.
MAI, 12 items from Form A and 18 items from Form B
were selected, and the statements taken from the selected
items were simplified because they were considered to
be difficult for children to understand. The Jr. MAI is a
Likert-type scale consisting of two forms, for different age
groups (Form A is for 3rd to 5th grade students and Form B
is for 6th to 9th grade students), that measures the level of
metacognitive skills without depending on a specific area
and in accordance with the development of metacognitive
skills. The items on Form A are answered on a 3-point
Likert-type scale (never, sometimes, and always), and
those on Form B are answered on a 5-point Likert-type
scale (never, seldom, sometimes, often, and always). A
high total score indicates high metacognitive skills (19).
The validity and reliability study for the Turkish version
of the Jr. MAI was performed by Karakelle and Saraç (21).
The Wechsler Intelligence Scale for Children-Revised
is one of the most widely used tests for measuring the
44
Metacognitive Awareness and Executive Function in ADHD
intelligence of children and adolescents. It consists of
12 subtests; six of the subtests are included in the verbal
scale, and six subtests make up the performance scale (22).
It was adapted into Turkish by Savaşır and Şahin (23).
The Behavioral Rating Inventory of Executive Function
is a behavioral rating measure that was specifically
designed to assess everyday executive skills in children
and adolescents in natural, everyday environments,
including the home and school (17). The BRIEF was
developed by Gioia et al. (17) to examine the associations
between performance-based measures of executive function
and ratings of executive function processes by parents
and teachers. It consists of two forms: the Parent Form and
Teacher Form. Both forms contain 86 questions, including
eight sub-domains. The Behavioral Regulation Index
(BRI) is composed of the Inhibit, Shift, and Emotional
Control sub-domains, and the Metacognition Index
(MI) is composed of the Initiate, Working Memory,
Plan/Organize, Organization of Materials, and Monitor
sub-domains. The BRI and MI are also combined to
obtain Global Executive Composite (GEC) scores (17).
High scores indicate high levels of executive impairment.
Reliability and validity studies of the BRIEF in a Turkish
normative sample were conducted by Batan et al. (24).
Conners’ Parent Rating Scale-Revised (CPRS-R) and
Conners’ Teacher Rating Scale-Revised (CTRS-R) are used
to collect information from parents or teachers about childhood
behavioral problems. CPRS-R is composed of seven
sub-scales: Cognitive problems, Oppositional, Hyperactivity-
Impulsivity, Anxious-Shy, Perfectionism, Social Problems,
and Psychosomatic (25). CTRS-R includes 6 sub-scales:
Oppositional, Cognitive Problems/Inattention, Hyperactivity,
Anxious-Shy, Perfectionism, and Social Problems (26).
Conners’ scales are available in both long and short versions.
Validity and reliability studies for the Turkish versions of
these scales have been performed previously (27, 28).
Statistical Analysis
Data were analyzed using IBM SPSS Statistics for
Windows, Version 22.0 (IBM Corp., Armonk, NY, U.S.A.).
The Shapiro-Wilks test was used to test for normality.
Descriptive statistics are expressed as the mean, standard
deviation, maximum, and minimum for the numerical
variables. Pearson’s correlation analysis was used to evaluate
the relationship between quantitative data showing a
normal distribution. The level of statistical significance
was predetermined to be p<0.05.
Regression analyses of the BRIEF-parent-emotional
control and initiate scores on the Conners’ parent scores
and the BRIEF-teacher inhibit, shift, emotional control,
initiate, working memory, plan/organize, organization of
materials, monitor, behavioral regulation index, metacognition
index, and global executive composite scores on the
Conners’ teacher scores were performed using backward
regression analysis.
Results
A total of 45 children with ADHD with a mean age of
9.7±2.2 (range: 7-14) years were included in the study;
23 (51.1%) were boys, and 22 (48.9%) were girls. The
mean age of the mothers was 33.8±4.1 years, and the
mean age of the fathers was 37.6±4.8 years; 13.3% of the
mothers and 15.6% of the fathers had a university degree
or higher. The scores of the scales used for the children,
parents, and teachers are summarized in Table 1.
Correlation analysis of the WISC-R-total score with the
BRIEF-parent scale and BRIEF-teacher scale scores showed
that there was a significant positive correlation between
WISC-R total and BRIEF-parent-initiate (r=0.315, p<0.040),
whereas no significant correlation was found with the other
sub-domains of the BRIEF scale (Table 2). Regression analysis
was not performed because only the BRIEF-parent-initiate
score was associated with WISC-R scores.
The correlation analysis of the Jr. MAI with the BRIEF
and Conners’ scales showed a significant negative correlation
between the Jr. MAI scores and BRIEF-parent-initiate
scores (r=-0.378, p<0.011); however, no significant correlation
was found with the other BRIEF sub-domains.
Moreover, no significant correlation was found between
the Conners’ scores and Jr. MAI scores (Table 3).
The correlation analysis between the BRIEF and
Conners’ scales completed by the parents revealed a
significant positive correlation between the Conners’
scores and BRIEF-emotional control (r=0.324, p<0.030)
and BRIEF-initiate (r=0.422, p<0.004) scores (Table 4).
The correlation analysis between the Conners’ teacher
and BRIEF-teacher-scales revealed a significant positive
correlation between the Conners’ teacher and all BRIEFteacher-
sub-domains (Table 5).
When we evaluated the effect of the BRIEF-parentemotional
control and initiate scores on the Conners’
parent scores using regression analysis, the model was
found to be significant (p<0.05), and the R-square value
was 0.213. The effect of the initiate scores on the model
was found to be statistically significant (p: 0.021; p<0.05).
A one-unit increase in the initiate scores increased the
Conners’ family scores by 0.75 units (Table 6).
45
Melek Gözde Luş and Habib Erensoy
When we evaluated the effect of the BRIEF-teacher
inhibit, shift, emotional control, initiate, working memory,
plan/organize, organization of materials, monitor, behavioral
regulation index, metacognition index, and global
executive composite scores, which are associated with
the Conners’ teacher scores, using backward regression
analysis, the model was found to be significant
(p<0.05), and the R-square value was 0.422. The effect of
the emotional control scores on the model was found to
be statistically significant (p<0.000; p<0.05). A one-unit
increase in the emotional control scores increased the
Conners’ teacher scores by 0.79 units.
Discussion
Children with ADHD have been reported to have lower
academic success compared to their peers. Although
the reason for this remains unclear, it is thought that the
learning process is negatively affected by the disease symptoms
and impaired executive functions (29). Attention
control and cognitive abilities are among the factors that
influence the learning processes (30, 31). Students who
use metacognitive strategies have been reported to be
more successful (32). In various studies performed on
school-age children, metacognitive education programs
have been shown to enhance academic performance (33,
34). It has been reported that metacognitive training
improves academic performance such as in mathematical
reasoning or reading comprehension and that it is particularly
important for intervention efforts to understand
Table 1. Scores of all scales used in the study
n Mean±SD
Minimum-
Maximum
WISC-R Verbal 44 88.2±14.08 64-114
WISC-R Performance 44 102.41±11.6 75-122
WISC-R Total 43 94.84±10.97 75-117
Jr. MAIa 45 37.96±17.26 20-83
Conners’-Parent 45 45.78±20.29 17-104
Conners’-Teacher 45 29.49±18.09 6-75
BRIEF-Parent 45
Inhibit 78.56±10.22 57-98
Shift 79.4±11.27 56-95
Emotional Control 64.04±10.15 43-83
Initiate 61.78±9.49 46-84
Working Memory 69.33±9.45 45-90
Plan/Organize 74.04±9.64 51-89
Organization of Materials 61.38±8.32 45-72
Monitor 60.67±9.47 43-88
Behavioral Regulation Index (BRI) 76.96±9.64 55-99
Metacognition Index (MI) 69.49±9.33 49-89
Global Executive Composite (GEC) 73.13±8.73 51-88
BRIEF-Teacher 45
Inhibit 76.96±15.18 49-124
Shift 78.78±19.86 46-127
Emotional Control 66.09±14.86 43-96
Initiate 66.56±15.38 39-97
Working Memory 72.53±18.47 40-113
Plan/Organize 80.27±13.51 52-107
Organization of Materials 61.29±13.44 42-99
Monitor 71.69±14.87 43-112
Behavioral Regulation Index (BRI) 76.51±16.09 47-121
Metacognition Index (MI) 74.84±15.85 44-113
Global Executive Composite (GEC) 76.64±15.62 47-121
aForm A was used in 29 children and Form B was used in 16 children
BRIEF, Behavioral Rating Inventory of Executive Function; Jr. MAI,
Metacognitive Awareness Inventory for Children; SD, Standard deviation;
WISC-R, Wechsler Intelligence Scale for Children-Revised
Table 2. Correlation analysis of the Wechsler Intelligence
Scale for Children-Revised total with the Behavioral Rating
Inventory of Executive Function -parent and -teacher scales
WISC-R total
r p
BRIEF-Parent scale subdomains
Inhibit -0.021 0.895
Shift 0.238 0.124
Emotional Control 0.231 0.137
Initiate 0.315 0.040
Working Memory 0.033 0.836
Plan/Organize 0.139 0.374
Organization of Materials 0.087 0.580
Monitor 0.222 0.153
Behavioral Regulation Index (BRI) 0.158 0.312
Metacognition Index (MI) 0.224 0.148
Global Executive Composite (GEC) 0.074 0.639
BRIEF-Teacher scale subdomains
Inhibit 0.042 0.787
Shift -0.073 0.643
Emotional Control -0.033 0.831
Initiate -0.157 0.316
Working Memory -0.054 0.731
Plan/Organize -0.215 0.166
Organization of Materials 0.026 0.870
Monitor -0.067 0.668
Behavioral Regulation Index (BRI) -0.006 0.972
Metacognition Index (MI) -0.031 0.845
Global Executive Composite (GEC) -0.061 0.700
BRIEF, Behavioral Rating Inventory of Executive Function; WISC-R,
Wechsler Intelligence Scale for Children-Revised
46
Metacognitive Awareness and Executive Function in ADHD
EF, metacognition, and how they relate with each other
(35). Tamm and Nakonezny (36) carried out a study on
children with ADHD and reported that executive function
training with a metacognitive focus was a potentially
promising intervention and that executive functions were
improved in the children who were trained, but they
emphasized that studies with larger sample sizes that
include active control groups are required to clarify the
subject. Basile et al. (37) investigated social information
processing from a metacognitive perspective. In their
study, the ADHD group was more confident in identifying
angry and sad faces than the normally developing
children, but the ADHD group exhibited lower resolution,
indicating that the normally developing group
was significantly better at discriminating correct from
Table 3. Correlation analysis of the Metacognitive Awareness
Inventory for Children with the Behavioral Rating Inventory of
Executive Function and Conners’ scales
Jr. MAI
r p
BRIEF-Parent scale subdomains
Inhibit 0.06 0.693
Shift -0.25 0.098
Emotional Control -0.009 0.956
Initiate -0.378 0.011
Working Memory -0.111 0.466
Plan/Organize -0.273 0.070
Organization of Materials -0.023 0.882
Monitor -0.097 0.528
Behavioral Regulation Index (BRI) -0.068 0.659
Metacognition Index (MI) -0.211 0.165
Global Executive Composite (GEC) 0.025 0.872
BRIEF-Teacher scale subdomains
Inhibit 0.093 0.541
Shift 0.165 0.278
Emotional Control 0.141 0.357
Initiate 0.08 0.601
Working Memory 0.165 0.278
Plan/Organize 0.144 0.344
Organization of Materials 0.06 0.694
Monitor 0.147 0.336
Behavioral Regulation Index (BRI) 0.139 0.364
Metacognition Index (MI) 0.055 0.720
Global Executive Composite (GEC) 0.180 0.236
Conners’-Parent -0.190 0.212
Conners’-Teacher -0.117 0.443
BRIEF, Behavioral Rating Inventory of Executive Function; Jr. MAI,
Metacognitive Awareness Inventory for Children
Table 6. Evaluation of the effect of Conners’ parent and
Conners’ teacher scores and BRİEF parent and teacher scale
subdomains by regression analysis
B S.E. Beta t p
Conners’ Parent and BRIEF-Parent scale
(Constant) -26,009 21,794 -1,193 0,239
Emotional 0,396 0,293 0,198 1,352 0,184
İnitiate 0,751 0,313 0,351 2,397 0,021*
Conners’ Teacher and BRIEF-Teacher scale
(Constant) -22,760 9,555 -2,382 0,022*
Emotional 0,791 0,141 0,650 5,602 0,000*
Table 4. Correlation analysis between the Conners’-Parent and
Behavioral Rating Inventory of Executive Function-parent scales
Conners’-Parent
r p
BRIEF-Parent scale subdomains
Inhibit 0.255 0.091
Shift 0.205 0.176
Emotional Control 0.324 0.030
Initiate 0.422 0.004
Working Memory 0.098 0.521
Plan/Organize 0.200 0.187
Organization of Materials 0.280 0.063
Monitor 0.263 0.081
Behavioral Regulation Index (BRI) 0.407 0.006
Metacognition Index (MI) 0.114 0.455
Global Executive Composite (GEC) 0.184 0.227
BRIEF, Behavioral Rating Inventory of Executive Function
Table 5. Correlation analysis between the Conners’-teacher and
Behavioral Rating Inventory of Executive Function-teacher scales
Conners’-Teacher
r p
BRIEF-Teacher scale subdomains
Inhibit 0.432 0.003
Shift 0.452 0.002
Emotional Control 0.650 <0.001
Initiate 0.427 0.003
Working Memory 0.328 0.028
Plan/Organize 0.317 0.034
Organization of Materials 0.318 0.033
Monitor 0.502 0.000
Behavioral Regulation Index (BRI) 0.576 0.000
Metacognition Index (MI) 0.344 0.021
Global Executive Composite (GEC) 0.477 0.001
BRIEF, Behavioral Rating Inventory of Executive Function
47
Melek Gözde Luş and Habib Erensoy
incorrect responses (37). Notably, metacognition has
often been neglected in theoretical models of executive
functions, and metacognition and executive functions
are closely linked (38).
In addition to impaired executive functions, difficulties
in metacognitive and behavioral regulation have also
been reported in children with ADHD (39). Pezzica et
al. (40) investigated the awareness of attention deficit
both in children with ADHD and in their peers without
ADHD. They concluded that children with and without
ADHD have almost similar degrees of metacognitive
awareness of attention and that children with ADHD
are aware of what is required in the school context but
are not able to meet the requirements. Therefore, in the
present study, we explored the relationship between
metacognitive awareness and executive functions in
children with ADHD. For this purpose, we measured the
level of metacognitive awareness of the children using the
Jr. MAI and evaluated the executive functions of children
using scales (BRIEF and Conners’ scale) completed by
the parents and teachers. Based on our findings, there
was no significant correlation between the Jr. MAI scores
and the scores of either the BRIEF (excluding parent-
BRIEF-initiate) or the Conners’ scale. Thus, no significant
interaction was found between metacognitive awareness
and executive functions in children with ADHD in the
present study group.
Given that the level of intelligence likely affects the
cognitive functions, the WISC-R test was also performed
with the children. In a literature review, Jepsen et al. (41)
evaluated the relationship between attention deficit and
IQ scores in treatment-naïve children with ADHD and
reported that the associations between IQ and attention
deficits in ADHD are generally modest, with the mean
influence on IQ probably amounting to 2 to 5 IQ points.
In addition, they also stated that in clinical practice, low
scores on a Wechsler IQ test for children and adolescents
with ADHD may not only reflect intellectual deficits but
also may be the result(s) of attention deficits during the
administration of the IQ test. In the present study group,
the total WISC-R score was 94.84±10.97 (range 75-117).
The absence of children with an IQ score <70, which is
considered as borderline intelligence, and the fact that
the mean scores corresponded to average intelligence
indicate that there was no problem in this regard in the
present study group. No significant correlation was found
between the total WISC-R score and the BRIEF scale subdomains
(excluding BRIEF-parent-initiate). Accordingly,
no significant interaction was found between the level
of intelligence and executive functions in children with
ADHD in the present study group.
When the Conners’ and BRIEF scales completed by
the parents were considered, a significant correlation
was found between two parent-BRIEF sub-domains
(emotional control and initiate) and the Conners’ scores.
For the scales completed by the teachers, a positive correlation
was found between the Conners’ scale scores
and all teacher-BRIEF scale sub-domains, suggesting
that more consistent evaluations were performed by
the teachers.
It has long been known that people with ADHD have
difficulty with emotional dysregulation (ED), and the
nature of the relationship between this difficulty and
ADHD is an interesting area of research. Studies have
shown that ED is frequently observed in ADHD, has an
effect on functioning, and is important in the course of
the disorder (42). One of the important limitations of
our study is that ED was not assessed, especially in the
families of children with ADHD.
In conclusion, the present study found no significant
correlation between metacognitive awareness and executive
functions or between the level of intelligence and
executive functions in children with ADHD. Further
studies on this topic that include larger sample groups
and control groups would clarify the physiopathological
mechanisms and provide beneficial information.
Ethical standards
The study was approved by the Ethics Committee of Haydarpaşa Numune
Training and Research Hospital. Informed consent from the parents and assent
from the patients were obtained.
Conflict of interest
The authors declare that they have no conflict of interest.
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Background: A pilot study was performed to examine
the relationship between metacognitive awareness and
executive functions in children with attention deficit/
hyperactivity disorder (ADHD).
Methods: Children who were diagnosed with ADHD and
were treatment naïve were consecutively included in
the study. The Wechsler Intelligence Scale for Children-
Revised (WISC-R) and the Metacognitive Awareness
Inventory for Children (Jr. MAI)-A and B forms were used.
The participants’ teachers and parents completed the
Behavioral Rating Inventory of Executive Function (BRIEF)
and Conners’ Rating Scale (CRS) forms.
Results: This study included 45 children with ADHD (51.1%
boys) with a mean age of 9.7±2.2 years. While the BRIEFparent-
initiate scores were positively correlated with
the WISC-R-total scores (r=0.315, p=0.040), they were
negatively correlated with the Jr.-MAI scores (r=-0.378,
p=0.011). No correlation was found between the Conners’
and Jr.-MAI scores. A positive correlation was found
between the Conners’-parent and the BRIEF-parentemotional
control (r=0.324, p=0.030) and BRIEF-parentinitiate
(r=0.422, p=0.004) scores. There were positive
correlations between the Conners’-teacher and all BRIEFteacher-
sub-domains.
Conclusion: Metacognitive awareness and executive
functions and intelligence level and executive functions
were not correlated in children with ADHD.
Introduction
Attention deficit/hyperactivity disorder (ADHD) is one
of the most frequently diagnosed neurodevelopmental
disorders during childhood and adolescence, with a
prevalence rate of 5% in children 4–17 years old (1).
ADHD is characterized by symptoms of inattention,
hyperactivity, and impulsivity at a frequency and intensity
inappropriate for the individual’s age and level of
development. ADHD does not involve a simple deficit
in attention; the symptoms have been associated with
deficits in executive function (EF). Several authors have
proposed that the symptoms of ADHD arise from a
primary deficit in a specific EF domain such as response
inhibition, working memory or a more general weakness
in executive control (2-7).
Metacognition is defined as an individual’s knowledge
of his/her cognitive processes and the ability to regulate
his/her own cognitive processes using this knowledge and
express the operations he/she uses to be aware of, monitor,
control, and regulate his/her cognitive processes (8, 9).
The cognitive processes that are monitored and regulated
include learning, problem solving, comprehension, reasoning,
and memory (9, 10). Children with ADHD often
have difficulties with inhibitory control and frequently
fail to manage or control their behavioral responses (11),
and in school, these children have difficulty maintaining
on-task behaviors or following through when given
instructions, producing work of poorer quality than they
are capable of (12, 13). A neurobiological dysfunction
involving regions of the prefrontal cortex associated with
behavioral inhibition is combined with the executive
dysfunctions in ADHD, especially regarding the multidimensional
EF system controlling higher-order cognitive
processes implemented by an executive prefrontal control
Metacognitive Awareness and Executive Function
in Attention Deficit/Hyperactivity Disorder
Melek Gözde Luş, MD,1 and Habib Erensoy, MD2
1 Haydarpaşa Numune Training and Research Hospital, Department of Child and Adolescent Psychiatry, University of Health Sciences,
Istanbul, Turkey
2 Psychiatry Department, Uskudar University, Istanbul, Turkey
43
Melek Gözde Luş and Habib Erensoy
network that interacts with the cortical and subcortical
affective networks (14, 15). The conceptual link between
behavioral inhibition, EF, and metacognition has led to
the hypothesis that children with ADHD may experience
difficulties in metacognition and, thus, that measures of
EF, especially behavioral inhibition and metacognition,
should be positively correlated. Because children with
ADHD encounter numerous psychosocial and occupational
challenges as they grow up, it is particularly
important for intervention efforts to understand EF,
metacognition, and how they relate to each other. Some
authors have reported that metacognitive interventions
for attention produce encouraging results with children
with ADHD, although the research is still limited (16).
There is continued interest in the research and clinical
utility of EF measures, including both neuropsychological
and behavioral ratings. The most frequently used rating
scale for EF is the Behavior Rating Inventory of Executive
Function (BRIEF) (17). Gioia et al. (17) used the standardized
parent and teacher report forms of the BRIEF
and reported that children with ADHD had significantly
higher scores on virtually all of the scales than the comparison
controls. Based on this knowledge, we aimed to
examine the relationship between metacognitive awareness
and executive functions in children with ADHD.
Our hypothesis is that children with ADHD will have
lower scores on learning behaviors and have lower academic
achievements. The second objective was to analyze the
relationships among EF, metacognitive awareness, and
symptoms of inattention and hyperactivity/impulsivity, and
identify which aspects of EF and/or ADHD symptoms have
greater relevance for metacognition in children with ADHD.
Our goal is that our study will aid in developing methods
to help students with ADHD achieve academic success
and lead to more effective intervention strategies.
Methods
Patients
All children who visited the Department of Child and
Adolescent Psychiatry in our hospital over a six-month
period and were diagnosed with ADHD were consecutively
included in the study. Children were diagnosed as having
ADHD according to a structured clinical interview based
on the criteria defined by the Diagnostic and Statistical
Manual of Mental Disorders-5th edition (DSM-5) (18).
The children with ADHD were included in the study on
condition that they were treatment naïve. The exclusion
criteria were the presence of a chronic medical illness, any
sensory-motor disability, neurological disorder, diagnosis
of autistic spectrum disorder, and other developmental
disorders. The entire initial number of children admitted
to our hospital during these six months was about 300.
However, 55 children with ADHD had severe comorbidities
such as major depression, mania, and bipolar disorder and
were excluded; 60 children with ADHD were taking medications
previously (31 children on methylphenidate and 29
children on atomoxetine) and were excluded. Ninety-five
of the children with ADHD did not agree to participate in
the study and 45 children with ADHD had chronic medical
illnesses. Children with any sensory-motor disability or
neurological disorder were excluded. Finally, 45 children
who were eligible to enter the study were selected.
Procedure
A clinician administered the Wechsler Intelligence Scale
for Children-Revised (WISC-R) and the Metacognitive
Awareness Inventory for Children (Jr. MAI)-A and B
forms. The participants’ teachers and parents completed
the Behavioral Rating Inventory of Executive Function
(BRIEF) and the Conners’ Rating Scale (CRS) forms. The
parents’ forms were completed by both the mother and
father. The teacher form was completed by the teacher of
each participant’s class.
Assessments
The Metacognitive Awareness Inventory for Children (Jr.
MAI) was developed by Sperling et al. (19) for children
and based on the MAI developed by Schraw and Dennison
(20) for adults. The MAI consists of 52 items; for the Jr.
MAI, 12 items from Form A and 18 items from Form B
were selected, and the statements taken from the selected
items were simplified because they were considered to
be difficult for children to understand. The Jr. MAI is a
Likert-type scale consisting of two forms, for different age
groups (Form A is for 3rd to 5th grade students and Form B
is for 6th to 9th grade students), that measures the level of
metacognitive skills without depending on a specific area
and in accordance with the development of metacognitive
skills. The items on Form A are answered on a 3-point
Likert-type scale (never, sometimes, and always), and
those on Form B are answered on a 5-point Likert-type
scale (never, seldom, sometimes, often, and always). A
high total score indicates high metacognitive skills (19).
The validity and reliability study for the Turkish version
of the Jr. MAI was performed by Karakelle and Saraç (21).
The Wechsler Intelligence Scale for Children-Revised
is one of the most widely used tests for measuring the
44
Metacognitive Awareness and Executive Function in ADHD
intelligence of children and adolescents. It consists of
12 subtests; six of the subtests are included in the verbal
scale, and six subtests make up the performance scale (22).
It was adapted into Turkish by Savaşır and Şahin (23).
The Behavioral Rating Inventory of Executive Function
is a behavioral rating measure that was specifically
designed to assess everyday executive skills in children
and adolescents in natural, everyday environments,
including the home and school (17). The BRIEF was
developed by Gioia et al. (17) to examine the associations
between performance-based measures of executive function
and ratings of executive function processes by parents
and teachers. It consists of two forms: the Parent Form and
Teacher Form. Both forms contain 86 questions, including
eight sub-domains. The Behavioral Regulation Index
(BRI) is composed of the Inhibit, Shift, and Emotional
Control sub-domains, and the Metacognition Index
(MI) is composed of the Initiate, Working Memory,
Plan/Organize, Organization of Materials, and Monitor
sub-domains. The BRI and MI are also combined to
obtain Global Executive Composite (GEC) scores (17).
High scores indicate high levels of executive impairment.
Reliability and validity studies of the BRIEF in a Turkish
normative sample were conducted by Batan et al. (24).
Conners’ Parent Rating Scale-Revised (CPRS-R) and
Conners’ Teacher Rating Scale-Revised (CTRS-R) are used
to collect information from parents or teachers about childhood
behavioral problems. CPRS-R is composed of seven
sub-scales: Cognitive problems, Oppositional, Hyperactivity-
Impulsivity, Anxious-Shy, Perfectionism, Social Problems,
and Psychosomatic (25). CTRS-R includes 6 sub-scales:
Oppositional, Cognitive Problems/Inattention, Hyperactivity,
Anxious-Shy, Perfectionism, and Social Problems (26).
Conners’ scales are available in both long and short versions.
Validity and reliability studies for the Turkish versions of
these scales have been performed previously (27, 28).
Statistical Analysis
Data were analyzed using IBM SPSS Statistics for
Windows, Version 22.0 (IBM Corp., Armonk, NY, U.S.A.).
The Shapiro-Wilks test was used to test for normality.
Descriptive statistics are expressed as the mean, standard
deviation, maximum, and minimum for the numerical
variables. Pearson’s correlation analysis was used to evaluate
the relationship between quantitative data showing a
normal distribution. The level of statistical significance
was predetermined to be p<0.05.
Regression analyses of the BRIEF-parent-emotional
control and initiate scores on the Conners’ parent scores
and the BRIEF-teacher inhibit, shift, emotional control,
initiate, working memory, plan/organize, organization of
materials, monitor, behavioral regulation index, metacognition
index, and global executive composite scores on the
Conners’ teacher scores were performed using backward
regression analysis.
Results
A total of 45 children with ADHD with a mean age of
9.7±2.2 (range: 7-14) years were included in the study;
23 (51.1%) were boys, and 22 (48.9%) were girls. The
mean age of the mothers was 33.8±4.1 years, and the
mean age of the fathers was 37.6±4.8 years; 13.3% of the
mothers and 15.6% of the fathers had a university degree
or higher. The scores of the scales used for the children,
parents, and teachers are summarized in Table 1.
Correlation analysis of the WISC-R-total score with the
BRIEF-parent scale and BRIEF-teacher scale scores showed
that there was a significant positive correlation between
WISC-R total and BRIEF-parent-initiate (r=0.315, p<0.040),
whereas no significant correlation was found with the other
sub-domains of the BRIEF scale (Table 2). Regression analysis
was not performed because only the BRIEF-parent-initiate
score was associated with WISC-R scores.
The correlation analysis of the Jr. MAI with the BRIEF
and Conners’ scales showed a significant negative correlation
between the Jr. MAI scores and BRIEF-parent-initiate
scores (r=-0.378, p<0.011); however, no significant correlation
was found with the other BRIEF sub-domains.
Moreover, no significant correlation was found between
the Conners’ scores and Jr. MAI scores (Table 3).
The correlation analysis between the BRIEF and
Conners’ scales completed by the parents revealed a
significant positive correlation between the Conners’
scores and BRIEF-emotional control (r=0.324, p<0.030)
and BRIEF-initiate (r=0.422, p<0.004) scores (Table 4).
The correlation analysis between the Conners’ teacher
and BRIEF-teacher-scales revealed a significant positive
correlation between the Conners’ teacher and all BRIEFteacher-
sub-domains (Table 5).
When we evaluated the effect of the BRIEF-parentemotional
control and initiate scores on the Conners’
parent scores using regression analysis, the model was
found to be significant (p<0.05), and the R-square value
was 0.213. The effect of the initiate scores on the model
was found to be statistically significant (p: 0.021; p<0.05).
A one-unit increase in the initiate scores increased the
Conners’ family scores by 0.75 units (Table 6).
45
Melek Gözde Luş and Habib Erensoy
When we evaluated the effect of the BRIEF-teacher
inhibit, shift, emotional control, initiate, working memory,
plan/organize, organization of materials, monitor, behavioral
regulation index, metacognition index, and global
executive composite scores, which are associated with
the Conners’ teacher scores, using backward regression
analysis, the model was found to be significant
(p<0.05), and the R-square value was 0.422. The effect of
the emotional control scores on the model was found to
be statistically significant (p<0.000; p<0.05). A one-unit
increase in the emotional control scores increased the
Conners’ teacher scores by 0.79 units.
Discussion
Children with ADHD have been reported to have lower
academic success compared to their peers. Although
the reason for this remains unclear, it is thought that the
learning process is negatively affected by the disease symptoms
and impaired executive functions (29). Attention
control and cognitive abilities are among the factors that
influence the learning processes (30, 31). Students who
use metacognitive strategies have been reported to be
more successful (32). In various studies performed on
school-age children, metacognitive education programs
have been shown to enhance academic performance (33,
34). It has been reported that metacognitive training
improves academic performance such as in mathematical
reasoning or reading comprehension and that it is particularly
important for intervention efforts to understand
Table 1. Scores of all scales used in the study
n Mean±SD
Minimum-
Maximum
WISC-R Verbal 44 88.2±14.08 64-114
WISC-R Performance 44 102.41±11.6 75-122
WISC-R Total 43 94.84±10.97 75-117
Jr. MAIa 45 37.96±17.26 20-83
Conners’-Parent 45 45.78±20.29 17-104
Conners’-Teacher 45 29.49±18.09 6-75
BRIEF-Parent 45
Inhibit 78.56±10.22 57-98
Shift 79.4±11.27 56-95
Emotional Control 64.04±10.15 43-83
Initiate 61.78±9.49 46-84
Working Memory 69.33±9.45 45-90
Plan/Organize 74.04±9.64 51-89
Organization of Materials 61.38±8.32 45-72
Monitor 60.67±9.47 43-88
Behavioral Regulation Index (BRI) 76.96±9.64 55-99
Metacognition Index (MI) 69.49±9.33 49-89
Global Executive Composite (GEC) 73.13±8.73 51-88
BRIEF-Teacher 45
Inhibit 76.96±15.18 49-124
Shift 78.78±19.86 46-127
Emotional Control 66.09±14.86 43-96
Initiate 66.56±15.38 39-97
Working Memory 72.53±18.47 40-113
Plan/Organize 80.27±13.51 52-107
Organization of Materials 61.29±13.44 42-99
Monitor 71.69±14.87 43-112
Behavioral Regulation Index (BRI) 76.51±16.09 47-121
Metacognition Index (MI) 74.84±15.85 44-113
Global Executive Composite (GEC) 76.64±15.62 47-121
aForm A was used in 29 children and Form B was used in 16 children
BRIEF, Behavioral Rating Inventory of Executive Function; Jr. MAI,
Metacognitive Awareness Inventory for Children; SD, Standard deviation;
WISC-R, Wechsler Intelligence Scale for Children-Revised
Table 2. Correlation analysis of the Wechsler Intelligence
Scale for Children-Revised total with the Behavioral Rating
Inventory of Executive Function -parent and -teacher scales
WISC-R total
r p
BRIEF-Parent scale subdomains
Inhibit -0.021 0.895
Shift 0.238 0.124
Emotional Control 0.231 0.137
Initiate 0.315 0.040
Working Memory 0.033 0.836
Plan/Organize 0.139 0.374
Organization of Materials 0.087 0.580
Monitor 0.222 0.153
Behavioral Regulation Index (BRI) 0.158 0.312
Metacognition Index (MI) 0.224 0.148
Global Executive Composite (GEC) 0.074 0.639
BRIEF-Teacher scale subdomains
Inhibit 0.042 0.787
Shift -0.073 0.643
Emotional Control -0.033 0.831
Initiate -0.157 0.316
Working Memory -0.054 0.731
Plan/Organize -0.215 0.166
Organization of Materials 0.026 0.870
Monitor -0.067 0.668
Behavioral Regulation Index (BRI) -0.006 0.972
Metacognition Index (MI) -0.031 0.845
Global Executive Composite (GEC) -0.061 0.700
BRIEF, Behavioral Rating Inventory of Executive Function; WISC-R,
Wechsler Intelligence Scale for Children-Revised
46
Metacognitive Awareness and Executive Function in ADHD
EF, metacognition, and how they relate with each other
(35). Tamm and Nakonezny (36) carried out a study on
children with ADHD and reported that executive function
training with a metacognitive focus was a potentially
promising intervention and that executive functions were
improved in the children who were trained, but they
emphasized that studies with larger sample sizes that
include active control groups are required to clarify the
subject. Basile et al. (37) investigated social information
processing from a metacognitive perspective. In their
study, the ADHD group was more confident in identifying
angry and sad faces than the normally developing
children, but the ADHD group exhibited lower resolution,
indicating that the normally developing group
was significantly better at discriminating correct from
Table 3. Correlation analysis of the Metacognitive Awareness
Inventory for Children with the Behavioral Rating Inventory of
Executive Function and Conners’ scales
Jr. MAI
r p
BRIEF-Parent scale subdomains
Inhibit 0.06 0.693
Shift -0.25 0.098
Emotional Control -0.009 0.956
Initiate -0.378 0.011
Working Memory -0.111 0.466
Plan/Organize -0.273 0.070
Organization of Materials -0.023 0.882
Monitor -0.097 0.528
Behavioral Regulation Index (BRI) -0.068 0.659
Metacognition Index (MI) -0.211 0.165
Global Executive Composite (GEC) 0.025 0.872
BRIEF-Teacher scale subdomains
Inhibit 0.093 0.541
Shift 0.165 0.278
Emotional Control 0.141 0.357
Initiate 0.08 0.601
Working Memory 0.165 0.278
Plan/Organize 0.144 0.344
Organization of Materials 0.06 0.694
Monitor 0.147 0.336
Behavioral Regulation Index (BRI) 0.139 0.364
Metacognition Index (MI) 0.055 0.720
Global Executive Composite (GEC) 0.180 0.236
Conners’-Parent -0.190 0.212
Conners’-Teacher -0.117 0.443
BRIEF, Behavioral Rating Inventory of Executive Function; Jr. MAI,
Metacognitive Awareness Inventory for Children
Table 6. Evaluation of the effect of Conners’ parent and
Conners’ teacher scores and BRİEF parent and teacher scale
subdomains by regression analysis
B S.E. Beta t p
Conners’ Parent and BRIEF-Parent scale
(Constant) -26,009 21,794 -1,193 0,239
Emotional 0,396 0,293 0,198 1,352 0,184
İnitiate 0,751 0,313 0,351 2,397 0,021*
Conners’ Teacher and BRIEF-Teacher scale
(Constant) -22,760 9,555 -2,382 0,022*
Emotional 0,791 0,141 0,650 5,602 0,000*
Table 4. Correlation analysis between the Conners’-Parent and
Behavioral Rating Inventory of Executive Function-parent scales
Conners’-Parent
r p
BRIEF-Parent scale subdomains
Inhibit 0.255 0.091
Shift 0.205 0.176
Emotional Control 0.324 0.030
Initiate 0.422 0.004
Working Memory 0.098 0.521
Plan/Organize 0.200 0.187
Organization of Materials 0.280 0.063
Monitor 0.263 0.081
Behavioral Regulation Index (BRI) 0.407 0.006
Metacognition Index (MI) 0.114 0.455
Global Executive Composite (GEC) 0.184 0.227
BRIEF, Behavioral Rating Inventory of Executive Function
Table 5. Correlation analysis between the Conners’-teacher and
Behavioral Rating Inventory of Executive Function-teacher scales
Conners’-Teacher
r p
BRIEF-Teacher scale subdomains
Inhibit 0.432 0.003
Shift 0.452 0.002
Emotional Control 0.650 <0.001
Initiate 0.427 0.003
Working Memory 0.328 0.028
Plan/Organize 0.317 0.034
Organization of Materials 0.318 0.033
Monitor 0.502 0.000
Behavioral Regulation Index (BRI) 0.576 0.000
Metacognition Index (MI) 0.344 0.021
Global Executive Composite (GEC) 0.477 0.001
BRIEF, Behavioral Rating Inventory of Executive Function
47
Melek Gözde Luş and Habib Erensoy
incorrect responses (37). Notably, metacognition has
often been neglected in theoretical models of executive
functions, and metacognition and executive functions
are closely linked (38).
In addition to impaired executive functions, difficulties
in metacognitive and behavioral regulation have also
been reported in children with ADHD (39). Pezzica et
al. (40) investigated the awareness of attention deficit
both in children with ADHD and in their peers without
ADHD. They concluded that children with and without
ADHD have almost similar degrees of metacognitive
awareness of attention and that children with ADHD
are aware of what is required in the school context but
are not able to meet the requirements. Therefore, in the
present study, we explored the relationship between
metacognitive awareness and executive functions in
children with ADHD. For this purpose, we measured the
level of metacognitive awareness of the children using the
Jr. MAI and evaluated the executive functions of children
using scales (BRIEF and Conners’ scale) completed by
the parents and teachers. Based on our findings, there
was no significant correlation between the Jr. MAI scores
and the scores of either the BRIEF (excluding parent-
BRIEF-initiate) or the Conners’ scale. Thus, no significant
interaction was found between metacognitive awareness
and executive functions in children with ADHD in the
present study group.
Given that the level of intelligence likely affects the
cognitive functions, the WISC-R test was also performed
with the children. In a literature review, Jepsen et al. (41)
evaluated the relationship between attention deficit and
IQ scores in treatment-naïve children with ADHD and
reported that the associations between IQ and attention
deficits in ADHD are generally modest, with the mean
influence on IQ probably amounting to 2 to 5 IQ points.
In addition, they also stated that in clinical practice, low
scores on a Wechsler IQ test for children and adolescents
with ADHD may not only reflect intellectual deficits but
also may be the result(s) of attention deficits during the
administration of the IQ test. In the present study group,
the total WISC-R score was 94.84±10.97 (range 75-117).
The absence of children with an IQ score <70, which is
considered as borderline intelligence, and the fact that
the mean scores corresponded to average intelligence
indicate that there was no problem in this regard in the
present study group. No significant correlation was found
between the total WISC-R score and the BRIEF scale subdomains
(excluding BRIEF-parent-initiate). Accordingly,
no significant interaction was found between the level
of intelligence and executive functions in children with
ADHD in the present study group.
When the Conners’ and BRIEF scales completed by
the parents were considered, a significant correlation
was found between two parent-BRIEF sub-domains
(emotional control and initiate) and the Conners’ scores.
For the scales completed by the teachers, a positive correlation
was found between the Conners’ scale scores
and all teacher-BRIEF scale sub-domains, suggesting
that more consistent evaluations were performed by
the teachers.
It has long been known that people with ADHD have
difficulty with emotional dysregulation (ED), and the
nature of the relationship between this difficulty and
ADHD is an interesting area of research. Studies have
shown that ED is frequently observed in ADHD, has an
effect on functioning, and is important in the course of
the disorder (42). One of the important limitations of
our study is that ED was not assessed, especially in the
families of children with ADHD.
In conclusion, the present study found no significant
correlation between metacognitive awareness and executive
functions or between the level of intelligence and
executive functions in children with ADHD. Further
studies on this topic that include larger sample groups
and control groups would clarify the physiopathological
mechanisms and provide beneficial information.
Ethical standards
The study was approved by the Ethics Committee of Haydarpaşa Numune
Training and Research Hospital. Informed consent from the parents and assent
from the patients were obtained.
Conflict of interest
The authors declare that they have no conflict of interest.
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