0(0), 1–12,

Journal of Clinical Child & Adolescent Psychology, 44(1), 20142015

145–156,
Copyright © Taylor & Francis Group, LLC
ISSN: 1537-4416 print/1537-4424 online
DOI: 10.1080/15374416.2013.873980

Meta-Worry, Worry, and Anxiety in Children and

Adolescents: Relationships and Interactions
B. H. Esbjørn, N. N. Lønfeldt, S. K. Nielsen, M. L. Reinholdt-Dunne, and M. J. Sømhovd
Department of Psychology, University of Copenhagen

S. Cartwright-Hatton
School of Psychology, University of Sussex

The metacognitive model has increased our understanding of the development and
maintenance of generalized anxiety disorders in adults. It states that the combination of
positive and negative beliefs about worry creates and sustains anxiety. A recent review
argues that the model can be applied to children, but empirical support is lacking. The aim
of the 2 presented studies was to explore the applicability of the model in a childhood
sample. The first study employed a Danish community sample of youth (n = 587) ages 7 to
17 and investigated the relationship between metacognitions, worry and anxiety. Two mul-
tiple regression analyses were performed using worry and metacognitive processes as out-
come variables. The second study sampled Danish children ages 7 to 12, and compared the
metacognitions of children with a GAD diagnosis (n = 22) to children with a non-GAD
anxiety diagnosis (n = 19) and nonanxious children (n = 14). In Study 1, metacognitive pro-
cesses accounted for an additional 14% of the variance in worry, beyond age, gender, and
anxiety, and an extra 11% of the variance in anxiety beyond age, gender, and worry. The
Negative Beliefs about Worry scale emerged as the strongest predictor of worry and a stron-
ger predictor of anxiety than the other metacognitive processes and age. In Study 2, children
with GAD have significantly higher levels of deleterious metacognitions than anxious chil-
dren without GAD and nonanxious children. The results offer partial support for the down-
ward extension of the metacognitive model of generalized anxiety disorders to children.

Anxiety disorders in childhood in general, and generalized
anxiety disorder (GAD) specifically, have a number of
immediate and long-term negative effects for the child, the
child’s family, and society at large. For instance, GAD in
childhood and adolescence is associated with thoughts of
suicide, social problems, and poor academic performance
(Albano & Hack, 2004), as well as a lowered quality of life
(Reinholdt-Dunne et al., 2011). The cardinal feature of
GAD is excessive and uncontrollable worry, although worry
also occurs in a variety of other psychological disorders
(Kertz, Bigda-Peyton, Rosmarin, & Bjorgvinsson, 2012).
Theorists believe that worry perpetuates and exacerbates
emotional distress (Cartwright-Hatton, 2006).
Evidence-based interventions targeting childhood worry
are lacking, and the behavioral techniques, which are the
focus of current treatment approaches for child anxiety,
may be ineffective against worry (Cartwright-Hatton,
2006). In contrast, metacognitive therapy, based on the
metacognitive model (MCM) of GAD (Wells, 1995), has
proven to be an effective treatment for adults suffering from
excessive worry (Sugiura, 2004; van der Heiden, Muris, &
van der Molen, 2012; Wells & King, 2006; Wells et al., 2010).
THE METACOGNITIVE MODEL OF
GAD IN ADULTS

Correspondence should be addressed to B. H. Esbjørn, Department A main tenet of the metacognitive model is that a
of Psychology, University of Copenhagen, Øster Farimagsgade 2A, Cognitive-Attentional Syndrome (CAS) underlies all
1353 Copenhagen K, Denmark. E-mail: barbara.hoff@psy.ku.dk emotional disorders (Wells & Matthews, 1996). CAS is
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ESBJØRN ET AL.
described as a state of mind in which attention is fixed
on negative self-thoughts (Wells & Carter, 1999; 2001). In
general, CAS is associated with an increase in cognitive
self-consciousness, beliefs that thoughts must be con-
trolled, and a decrease in cognitive confidence. Further-
more, CAS is associated with the presence of positive
and negative metabeliefs. According to the metacogni-
tive model of GAD in adults, it is not the excessiveness
or the content of worry but the metacognitive beliefs
held about worry that are problematic (Wells, 1995).
The model claims that positive and negative beliefs
about worry cause normal worry to become maladap-
tive. Wells proposed that positive beliefs about worry
prime the use of worry as a strategy for coping with, pre-
paring for, or avoiding negative future outcomes. These
positive beliefs are held both by people with and without
GAD. However, when worry becomes excessive, negative
metabeliefs about worry (e.g., that worry is uncon-
trollable and that it can lead to negative consequences
for the worrier) activate “metaworry’’ (worry about
worry; Wells, 1995). Although the MCM of GAD for
adults proposes that positive and negative beliefs about
worry lead to the development and maintenance of
GAD, it is the negative beliefs about worry which
distinguish normal worry from the complicated worry
found in GAD sufferers (Wells, 1995). Research involv-
ing adults supports this supposition (Cartwright-Hatton &
Wells, 1997; Davis & Valentiner, 2000; Wells &
Carter, 2001; Wells & Papageorgiou, 1998).
THE METACOGNITIVE MODEL OF
GAD IN CHILDREN
Unlike adult GAD, little is known about GAD in
children (Cartwright-Hatton, Reynolds, & Wilson,
2011). A recent literature review, evaluating the applica-
bility of the metacognitive model of GAD in children
and adolescents, concluded that an extension of Wells’s
(1995) model to children is promising (Ellis & Hudson,
2010). This conclusion was based on developmental
literature suggesting that children are capable of many
of the cognitive components of the Wells model. For
instance, young children from around the age of 4 years
possess metacognitive knowledge such as knowing that
the content of thoughts can include things that are not
present, and from the age of 6 years children are capable
of knowing when and how they came to know some-
thing (Flavell, 1999). Between the ages of 5 and 8, chil-
dren acquire the knowledge that attention is selective
and limited (Pillow, 2008). A finding directly relevant
to the MCM is that 9-year-olds, like adults, understand
that thoughts can be automatic and difficult to control
(Flavell, Green, & Flavell, 1998). The clinical literature
offers findings even more pertinent to the applicability
of the MCM to children. A study on childhood worry
revealed that children between the ages of 8 and 13
can think of worry as difficult to control and use distrac-
tion strategies and discussion of their worries to deal
with them. Moreover, some endorsed benefits (i.e., positive
beliefs) of worrying (Muris, Meesters, Merckelbach,
Sermon, & Zwakhalen, 1998). A recent study found that
56% of children sampled between 6 and 10 years of age
endorse positive beliefs (e.g., “worry makes you think
things through first,’’ “worry keeps you safe’’; p. 8) and neg-
ative beliefs about worry (e.g., “worry can make your
tummy hurt,’’ “worry makes you not concentrate’’; p. 9),
with no age-related effect within this age-range (Wilson &
Hughes, 2011). The lack of age-related effect in relation to
metacognition is corroborated by other studies assessing
samples with wider age ranges, for example, adolescents
aged 13 to 17 years (Cartwright-Hatton et al., 2004; Ellis &
Hudson, 2011) and children aged 9 to 17 years (Esbjørn
et al., 2013), but not all (Bacow, Pincus, Ehrenreich, &
Brody, 2009). The latter study reported an increase in
cognitive monitoring with age in a sample of 7- to
17-year-old youth.
If the MCM is applicable to children, then research
should demonstrate associations between metabeliefs
and worry and anxiety in younger samples, as are found
in adult populations (Barahmand, 2009; Wells & Carter,
1999, 2001; Yilmaz, Gencoz, & Wells, 2008). Research
in child populations supports some of these connections.
Findings on the occurrence of negative beliefs about
worry in youth with anxiety disorders are mixed. In sup-
port of the MCM, anxious youth rate their worries as
more intense than nonanxious youth (Perrin & Last,
1997), and youth with specific phobia (Weems, Silverman, &
La Greca, 2000). However, another study found no
significant difference in level of negative beliefs about
worry held by clinical and nonclinical youth (Bacow
et al., 2009). A second publication based on the same
sample also reported no differences between children
and adolescents with a principal diagnosis of GAD com-
pared to other types of anxiety disorders on need to con-
trol thoughts, negative, and positive metabeliefs (Bacow,
May, Brody, & Pincus, 2010). A finding in this study was
that the control group endorsed higher levels of cognitive
monitoring than the clinical groups with generalized and
separation anxiety disorders. The conclusions that may
be drawn are limited by the high number of youth with
subclinical psychopathology levels in the nonclinical
group (Bacow et al., 2010).
Contrasting these findings, two recent studies of clini-
cal youth reported elevated levels of both positive and
negative metacognitions compared to nonclinical con-
trols (Ellis & Hudson, 2011; Smith & Hudson, 2013).
Clinically anxious adolescents, however, did not differ
from nonclinical controls on the cognitive confidence
and cognitive self-consciousness subscales but did report

METACOGNITIONS ININ CHILDREN
higher levels of metacognitions regarding the need to
control thoughts to prevent bad things from happening
(Ellis & Hudson, 2011). Adolescents who fulfilled criteria
for a GAD diagnosis did not differ from adolescents who
suffered from anxiety other than GAD when post hoc
corrections were conducted (Ellis & Hudson, 2011).
Overall, the MCM has received partial support in
clinically anxious child and adolescent samples at
present. It remains unclear whether negative metacogni-
tions can distinguish between youth with GAD and
those with other types of anxiety disorders and what
role, if any, positive metacognitions may play in child-
hood anxiety disorders. Therefore, the aim of the
present study is to test the applicability of the MCM
of GAD to children and adolescents by answering the
question, Do children and adolescents experience similar
processes in GAD and worry as those found in adults?
We address this question in two studies investigating
first a community sample of youth and second a clini-
cally anxious sample and a nonanxious control sample
of children.
STUDY 1
Study 1 seeks to test the MCM in youth by investigating
the relationship between metacognitions and worry and
anxiety in a community sample of children and adoles-
cents and assess the strength of the MCM in predicting
pathological worry and anxiety in youth. Based on the
MCM of GAD, we hypothesize that there will be posi-
tive relationships between positive metacognitive beliefs
and levels of anxiety and worry. We also hypothesized
that negative beliefs about worry, as the driving factor
in GAD (Wells & Carter, 2001), will have the greatest
influence on the variance of worry and anxiety levels.
Methods
Participants
Participants were recruited from public schools in
Denmark, Grades 4 through 9 (Mdn grade = 6; age
range = 9–17 years). A total of 1,134 children and ado-
lescents participated in an extensive testing battery pro-
viding data to a number of studies. We expected this to
increase the risk of randomly missed items. We replaced
missing scores with the mean of the scales, when 20% or
fewer of the items were missing in a scale. Children with
more than 20% missing on any of the applied scales were
eliminated from the present study. Thus, the final sam-
ple consisted of 587 youth, after eliminating cases with
missing data (n = 547). We found no statistical differ-
ences in gender, parental education, number of par-
ents in the home, or family income between participating
METACOGNITIONS
CHILDREN AND
AND ADOLESCENTS
ADOLESCENTS 147
3
children and those who were eliminated from the present
study due to incomplete questionnaires. A statistically
significant difference in age, t(1096) = −7.01, p < .0001,
was found between those who were excluded from the
study (M = 11.90, SD = 1.59) and those who were
included (M = 12.59, SD = 1.66). However, the differ-
ence between means was just 6 months of age.
Of the final sample, 300 (51%) were children (9–12
years of age; M = 11 years, SD = 9.9 months), 165
(55%) of whom were female. Adolescents made up 287
(49%) of the participants (13–17 years of age; M = 14
years, SD = 10.8 months); 157 (55%) were female. The
sample was selected to include children attending fourth
grade through the end of public school (ninth grade). By
fourth grade, most children are expected to have
acquired sufficient reading skills to complete question-
naires. Adolescents were sampled in addition to children
in order to examine any age-related effects.
Measures
Metacognitive beliefs. The Metacognitions Ques-
tionnaire for Children 30 (MCQ-C30; Esbjørn et al.,
2013) is a translation of the German Meta-Kognitions
Fragebogen fur Kinder (Gerlach, Adam, Marschke, &
Melfsen, 2008), which is a simplified version of the
adolescent version of the MCQ (MCQ-A; Cartwright-
Hatton et al., 2004). In contrast to the MCQ-C (Bacow
et al., 2009), it contains all of the original five subscales
that make up the adolescent and adult versions of the
questionnaire. It assesses metacognitive processes based
on five fundamental tenets of the MCM: “positive beliefs
about worry’’; “negative beliefs about worry’’; “low cog-
nitive confidence’’ (which is thought to increase attempts
to control thoughts); “the need to control thoughts to
avoid negative consequences’’ (which is thought to result
in attempts to suppress “dangerous’’ thoughts); and
“cognitive self-consciousness,’’ which assesses the
general activity of “self-referent processing’’ (which is
purposed to make worry and meta-worry worse; Wells,
1995). Metacognitive beliefs are assessed on a 4-point
scale from 1 (not at all)to 4 (completely). Higher sum-
scores of the full scale and five subscales indicate a greater
number and strength of meta-beliefs endorsed. Other
studies support a five-factor structure of the MCQ-C30,
and significant and strong correlations between the
MCQ-C30 and a measure of worry indicate strong
concurrent validity. The internal consistency of the
MCQ-C30 scale has also been reported to be
satisfactory for youth aged 9 to 17 years (Esbjørn et al.,
2013).
Worry. The Penn State Worry Questionnaire for
Children (PSWQ-C; Chorpita, Tracey, Brown, Collica, &
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ESBJØRN ET AL.

Barlow, 1997) measures the intensity and uncontroll-
ability of worry in children on a 4-point scale ranging
from 0 to 3. A total sumscore is calculated (after recod-
ing three reversed items) with higher scores indicating
more worry. The Danish version of the PSWQ-C
demonstrates high internal consistency and moderate
to high convergent validity (Esbjørn, Reinholdt-Dunne,
Caspersen, Christensen, & Chorpita, 2012).
Anxiety. Screen for Child Anxiety Related Emotional
Disorders (SCARED-R; Muris, Merckelbach, Schmidt, &
Mayer, 1999; Muris, Merckelbach, van Brakel, & Mayer,
1999) measures child anxiety disorders as defined by the
Diagnostic and Statistical Manual of Mental Disorders
(4th ed. [DSM-IV ]; American Psychiatric Association,
1994). The 69 items are scored on a 3-point scale of 0
(almost never), 1 (sometimes), and 2 (often). The original
and Danish version of the measure are reported to
have good internal consistency, satisfactory test-retest
reliability, and discriminant validity (Esbjørn, Sømhovd,
Caspersen, & Reinholdt-Dunne, 2012; Muris, Dreessen,
Bogels, Weckx, & van Melick, 2004; Muris, Merckelbach,
Schmidt, et al., 1999).
Procedure
variable. Second, the multiple regression analysis was
run adding each of the five metacognitive processes
(subscales from the MCQ-C30) as covariates to assess
if they could explain the variance in worry and anxiety
beyond the effect of gender, age, and anxiety or worry
in the first step.
Results
The results of the regression of worry scores (PSWQ) on
gender, age, anxiety, and MCQ-C30 scores are presented
in Table 1. In the first step, gender, age, and anxiety
predicted a significant proportion of the variance in
worry (R2 = .32), F(3, 583) = 91.21, p < .0001. Adding the
set of metacognitive processes made an additional
individual and significant contribution to the variance
in worry (∆R2 = .46), F(8, 578) = 61.92, p < .0001. The
metacognitive processes accounted for an extra 14% of
the variance in worry beyond the effect of gender, age,
and anxiety. The Positive and Negative Beliefs About
Worry scales, as well as the Cognitive Confidence and
Cognitive Self-Consciousness made significant contribu-
tions to the variance of worry, with negative metabeliefs
emerging as the strongest overall predictor of worry.
Gender and the Need for Control scale, however, did
not add to the model’s predictive ability of worry.

An invitation letter was sent to all 210 primary

TABLE 1
schools in Denmark that had more than three classes Summary Statistics for the Regression Equations
in each grade. Nineteen schools consented to partici- With Worry and Anxiety as Outcome Variables
pate. Following Danish ethical guidelines, teachers
Worry Anxiety
distributed information letters to families and subse-
quently collected written consent from parents. The B SE B b B SE B b
participating schools were geographically diverse, repre-
Step 1
senting urban and rural areas in all of Denmark. Project
Constant −3.08 2.23 43.67 4.49
staff administered the test battery in a predetermined Gender 1.54 0.54 0.10* −10.58 1.10 −0.31***
order, providing aid as needed. Assent to participate Age 0.53 0.15 −0.12** −1.10 0.33 −0.11**
from the youth was obtained orally, and the children SCARED-R/ 0.26 0.02 0.59*** 1.20 0.08 0.52***
were tested in a classroom where their peers could not PSWQ-C
Step 2
see their responses to the questions. The youth were given
Constant −10.19 2.19 15.84 4.48
a small token of appreciation for their participation Gender 0.55 0.50 0.04 −10.58 1.01 −0.31***
(a pencil or pen). Age 0.45 0.14 0.10** −0.79 0.30 −0.08*
SCARED-R/ 0.13 0.02 0.31*** 0.65 0.09 0.28***
PSWQ-C
Data Analysis MCQ-C30 POS 0.27 0.99 0.09 −0.20 0.22 −0.03
MCQ-C30 NEG 0.92 0.10 0.37*** 1.15 0.24 0.20***
To test whether positive and negative metacognitions MCQ-C30 CC −0.18 0.09 −0.07* 0.72 0.19 0.12***
are significant predictors of pathological worry and MCQ-C30 NC 0.16 0.13 0.06 0.94 0.28 0.14**
anxiety in children, a multiple regression analysis was MCQ-C30 CSC 0.18 0.09 0.08* 0.45 0.19 0.08*
run twice, first with PSWQ-C (measuring worry) as the Note: For worry as outcome variable: R2 = .02 for Step 1 (p < .01),
outcome variable, and second with SCARED-R (mea- ∆R2 = .41 for Step 2 (p < .0001); p < .05. p < .005. p < .0001. For anxiety
suring anxiety generally) as the outcome variable. Given as outcome variable: R2 = .40 for Step 1, ∆R2 = .51 for Step 2 (p < .0001);
the established effects of age and gender on reports of p < .05. p < .005. p < .0001. SCARED-R = Screen for Child Anxiety
worry and anxiety, age and gender were entered as Related Emotional Disorders-Revised; PSWQ-C = Penn State Worry
Questionnaire for Children; MCQ-C30 = Metacognitions Questionnaire
covariates in the first step of both analyses. As worry and for Children-30; POS = Positive Beliefs About Worry; NEG = Negative
anxiety are significantly correlated, they were each Beliefs About Worry; CC = lack of Cognitive Confidence; NC = Need
added as a covariate when the other was the outcome for Control; CSC = Cognitive Self-Consciousness.

METACOGNITIONS ININ CHILDREN
Somewhat similar results were found when anxiety
(SCARED-R) was the outcome variable (see Table 1).
Gender, age, and worry predicted a significant pro-
portion of the variance in anxiety (R2 = .40), F(3,
583) = 132.22, p < .0001. However, the set of metacogni-
tive processes made an individual and significant contri-
bution to the variance in anxiety scores when added
to the model (∆R2 = .51), F(8, 578) = 76.43, p < .0001,
accounting for an extra 11% of the variance in anxiety.
The Negative Beliefs About Worry scale emerged as a
stronger predictor of anxiety than the other metacogni-
tive processes, age, and even worry; The Positive Beliefs
About Worry scale was the only metacognitive subscale
that did not improve the predictive ability of the model.
Overall, gender provided the largest contribution to the
predictive strength of the model, with girls reporting
higher levels of anxiety than boys.
Discussion
Results from the regression analyses offer further sup-
port for the extension of the MCM of GAD to children.
Metacognitive processes accounted for an extra 14% of
the variance in worry beyond the effects of gender, age,
and anxiety, and an additional 11% of the variance in
anxiety in youth beyond the effects of gender, age, and
worry. This supports the primary hypothesis that the
MCM has predictive value in levels of worry and anxiety
symptoms in children and adolescents. The results are
also consistent with previous findings. For example, in an
adult sample, metacognitive processes predicted anxi-
ety independently of gender, and worry (Spada et al.,
2011), and positive beliefs about worry predicted the
variance in worry scores in adolescents (Laugesen,
Dugas, & Bukowski, 2003). In our study, positive meta-
beliefs about worry did not predict anxiety symptoms,
which is in contrast to the findings of two other studies
of youth (Ellis & Hudson, 2011; Smith & Hudson,
2013). These studies reported positive associations
between positive metabeliefs and anxiety symptoms
and emotional symptoms; this lack of consistency may
have been caused by differences in methodological
approach. In our study, we controlled for level of worry
in our analyses of anxiety symptoms. As worry and anxi-
ety are correlated, this may explain the lack of predictive
power of the positive beliefs in relation to anxiety in our
study. The inability to predict the presence of anxiety
based on positive beliefs is consistent with previous find-
ings in both adults and youth (Bacow et al., 2009;
Cartwright-Hatton & Wells, 1997). Finally, in our study,
negative beliefs about worry explained the most variance
in worry compared to any other predictor in the model
and more of the variance in anxiety scores than the other
metacognitive processes. This is also in line with previous
findings from adult (Spada, Mohiyeddini, & Wells, 2008)
METACOGNITIONS
CHILDREN AND
AND ADOLESCENTS
ADOLESCENTS 149
5
and child research (Ellis & Hudson, 2011; Smith &
Hudson, 2013).
In the second regression model, gender made the lar-
gest contribution to the variance in anxiety scores, with
girls reporting more anxiety than boys. This finding may
be explained by girls reporting significantly higher meta-
cognitions and anxiety than boys. Indeed, a study using
a sample related to the current one found that level of
anxiety mediated the relationship between female gender
and higher scores on the metacognitions questionnaire
(Esbjørn et al., 2013). The recent findings are consist-
ent with a previous study that found that girls report
higher negative repetitive thinking and anxiety (Muris,
Roelofs, Meesters, & Boomsma, 2004), suggesting that
it is plausible that girls hold more maladaptive metacog-
nitions than boys. The Need for Control scale offered
the second largest contribution to the variance in
anxiety among the metacognitive processes, although it
did not significantly contribute to the variance in worry
scores. According to the metacognitive theory of
emotional disorder, the Need for Control scale is more
characteristic of obsessive-compulsive disorder (OCD)
than it is of GAD (Wells, 2000). The SCARED-R incor-
porates OCD symptoms to a greater extent than the
PSWQ-C scale, which may in part explain this difference
in results.
STUDY 2
The second study is one of few that explore metacogni-
tions in children as young as 7 years, and it is the first to
do so using the MCQ-C30. Furthermore, it expands the
findings from Study 1 by including children with clinical
levels of anxiety. The MCM of GAD for children is
tested by comparing a group of children with GAD, a
group of children with anxiety disorders other than
GAD (Oth.AD), and a nonclinical control group of
children.
Based on theory, we expect to find that children with
GAD have more negative beliefs about worry than both
non-clinical children, and children with other anxiety
disorders. Furthermore, as all metacognitive processes
play a role in the development and maintenance of
emotional disorders in adults, we expected that anxious
(Oth.AD) children should endorse more metacognitive
beliefs than non-anxious children. Previous findings
offer conflicting results in respect to differences in meta-
cognitive processes in clinically anxious and nonanxious
youth (Bacow et al., 2010; Cartwright-Hatton et al.,
2004). In addition, studies including childhood and
adolescent samples have not, as the theory suggests,
been able to differentiate GAD samples from samples
with other anxiety disorders (Bacow et al., 2010; Ellis &
Hudson, 2011). In accordance with the metacognitive
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ESBJØRN ET AL.
theory of adult GAD, we hypothesized that (a) there
would be no significant differences between levels of
positive meta-beliefs between the clinical and nonclinical
children and (b) that the GAD group would endorse
significantly more negative metacognitive beliefs than
the Oth.AD group and the nonclinical group.
Methods
Participants
Children with anxiety disorders aged 7 to 13 years,
who were recruited for a randomized treatment project
were also enrolled in the present project. Control chil-
dren without disorders were selected to resemble the
clinical sample. The project enrolled 99 families between
February 18, 2009, and July 20, 2012. Six families were
excluded from the main data analysis because of missing
data on the MCQ-C30. Participants in the final data set
(N = 93) ranged in age from 7 to 12 years and had a
mean age of 9 years and 9.36 months (SD = 1 year
7.68 months), and 46 (49.5%) of the participants were
girls. Children as young as 7 years old were sampled
because at this age many children are capable of the
metacognition required by the MCM. Adolescents older
than 13 years were not included as the sample came from
a larger clinical trial focused on children. All part-
icipants had at least one native Danish-speaking parent.
School psychologists, physicians, or parents referred
clinical participants to the study.
Parents and children in the control group volunteered
participation after receiving an information letter that
they received by post or via their teacher. All parti-
cipants provided written informed consent. During test-
ing, questionnaires were read out loud to any children
who did not have sufficient reading skills to read them-
selves. To ensure that those who read the questions
themselves did this correctly, they were asked to read
the questions out loud before answering them.
Measures
Metacognitive beliefs. For a description of the
MCQ-C30, see Study 1. As the MCQ-C30 had not been
validated on children younger than 9 years of age, we
calculated the internal consistency for the children 7 to
8 years of age (n = 23) using Cronbach’s alpha. The
internal consistency for the total score was excellent
(a = .91). The subscales of Positive beliefs, Negative
Beliefs, and Cognitive Self-Consciousness all displayed
acceptable internal consistency (a = .73, .71, .75, respect-
ively), whereas the Need to Control Thoughts and
Cognitive Confidence displayed lower, yet acceptable,
internal consistency (a = .62, .69).
Anxiety diagnosis. The Anxiety Disorders
Interview Schedule for DSM-IV, Child and Parent
Versions (ADIS-IV-C/P; Silverman & Albano, 1996)
were used for diagnosing anxiety disorders. The
ADIS-IV-C/P comprises independent parent and child
semistructured interviews, which are designed to elicit
information on DSM-IV-defined symptoms of anxiety
disorders, and other psychopathology. A clinical sever-
ity rating (CSR) scale ranging from 0 to 8 is used to rate
the severity of symptoms. Clinical levels of difficulties
receive a score of 4 or greater. In the present study,
the applied diagnoses were the composite score from
the child and parent interviews. All interviews were
administered by students or staff who had received
training in administering and scoring of the interview.
Ongoing supervision was provided throughout the pro-
ject period to ensure reliability of the diagnoses. Consen-
sus scores were created based on video recordings of the
interviews, in cases that were difficult or ambiguous.
To compare the metacognitions of children with
GAD to those with other anxiety disorders and nonan-
xious children, the ADIS-C/P was used to categorize
children into the three diagnostic groups: GAD, other
anxiety disorder, and nonclinical.
The GAD group was created using similar criteria as
applied in the study by Ellis and Hudson (2011): A total
of 22 children met criteria for GAD as a primary
(n = 11), secondary (n = 9), or tertiary (n = 2) diagnosis.
Those with a secondary or tertiary GAD diagnosis had
separation anxiety (n = 7) and specific phobia (n = 4) as
their primary disorders. Ten children (46%) in the GAD
group had a secondary disorder, and 11 (50%) also had
a tertiary disorder. All of these were anxiety disorders,
except for one child, who had a tertiary mood disorder.
The Oth.AD group comprised 28 children who did
not meet criteria for GAD but had separation anxiety
disorder (n = 17), specific phobia, (n = 8), or social
phobia (n = 3) as their primary disorder. Children with
a primary disorder of OCD are, unlike the other anxiety
disorders, typically treated in the psychiatric system in
Denmark and were therefore not enrolled in the present
study. Nine children (32%) in the Oth.AD group had a
secondary disorder, and eight (29%) also had a tertiary
disorder. Apart from other anxiety disorders, the
secondary disorders consisted of one case of OCD,
mood disorder, and posttraumatic stress disorder, and
one tertiary disorder of defiant behavior/conduct
disorder.
Control children (n = 43) did not meet criteria for any
disorder assessed by the ADIS-IV-P. Informants were
asked to provide CSRs only if the required number of
symptoms and criteria for receiving a diagnosis were
met. No child in the nonclinical group met the diagnos-
tic criteria required to warrant a CSR. Therefore, they
received a CSR of zero.
 METACOGNITIONS
METACOGNITIONS ININ CHILDREN
CHILDREN AND
AND ADOLESCENTS
ADOLESCENTS 151
7

Ethical Considerations Finally, no differences were found in mean age between

The study was approved by the Internal Ethical
Review Board of the University of Copenhagen,
Denmark. The project adhered to national and
university-specific ethical guidelines regarding clinical
projects. Questionnaire packages were mailed to the
families and completed at home. Oral assent was
obtained by the child prior to further assessment,
which was conducted by trained project staff. All clini-
cally anxious children were provided with cognitive
behavior treatment at the anxiety clinic, whereas,
children in the control sample were given a gift certificate
as an expression of appreciation for their participation.
Data Analysis
Mann-Whitney tests were performed to determine
whether the control group and the combined clinical
groups differed in household income or parental edu-
cation level. Chi-square was employed to detect possible
gender differences between the three groups. A one-way
analysis of variance was calculated to examine age
differences between groups.
For the main analyses, a multivariate analysis of
variance (MANOVA) was run with diagnostic group
as the independent variable and the five metacognitive
processes as the dependent variables. The multivariate
test statistic Pillai’s trace was used as it is considered
the most conservative and robust method (Field,
2009), due to unequal sample sizes and inequality of
covariances of the present data. Finally, post hoc
Bonferroni analyses were conducted to determine
between-group differences on the subscale level.
the control, Oth.AD, and GAD groups.
Effects of Diagnosis on Metacognitions
The MANOVA revealed a significant multivariate
main effect for diagnostic group using Pillai’s trace,
V = 0.42, F(10, 174) = 4.69, p < .05, h2 = .21. Group
total and subscale mean scores on the MCQ-C30 for
the three diagnostic groups are reported in Table 2.
The GAD group scored highest on all of the subscales,
followed by the group with other anxiety diagnoses,
and the control group scored lowest. Post hoc Bonfer-
roni analyses revealed that there were no differences
between the control group and Oth.AD group on Posi-
tive Beliefs, Cognitive Confidence, or Cognitive
Self-Consciousness. However, the Oth.AD group had
significantly higher levels of Negative Beliefs (p < .01) and
Need to Control Thoughts ( p < .01) compared to
the control group.
Further, the GAD group endorsed higher levels of
metacognitive beliefs than the control group on all sub-
scales (POS: p = .03; NEG: p < .01; NC: p < .01; CC:
p = .04) except the Cognitive Self-Confidence scale.
The GAD group also held higher levels ofmetacognitive
beliefs than the other anxiety group on the Negative
Beliefs subscale ( p = .04).
Discussion
Negative Metabeliefs
Results of the MANOVA support our hypothesis
that children with GAD would endorse significantly
more negative beliefs about worry than children with

Results
Demographics
TABLE 2
The Mann-Whitney tests suggest that control and Means and Standard Deviations for Diagnostic
clinical participants were comparable in terms of Groups on Metacognitive Factors
mother’s level of education and household income. Controla Oth.ADb GADc
However, the fathers of the children in the
clinical groups (Mdn = 4.00; medium-length practical MCQ-C30 POS 7.78 (2.24) 8.72 (2.63) 9.50 (2.79)
MCQ-C30 NEG 8.67 (2.25) 12.39 (4.25) 15.41 (6.57)
education) had a significantly lower level of formal
MCQ-C30 CC 8.47 (2.35) 10.14 (2.90) 10.64 (4.19)
education compared to fathers of children in the control MCQ-C30 NC 8.75 (1.95) 11.03 (3.37) 11.41 (3.22)
group (Mdn = 5.00; master’s-level education or higher), MCQ-C30 CSC 12.05 (4.46) 12.07 (3.91) 14.18 (3.21)
U = 408.50, z = −2.83, p < .01. The modal level of MCQ-C30 Total 45.57 (9.25) 54.40 (13.51) 61.11 (12.43)
education of mothers of nonanxious children was at Note: Standard deviations in parentheses. MCQ-C30 =
the master’s level or higher, whereas that of mothers Metacognitions Questionnaire for Children-30; POS = Positive Beliefs
of children with clinical anxiety tended to be at the About Worry; NEG = Negative Beliefs About Worry; CC = Lack
bachelor level, but this difference was not significant. of Cognitive Confidence; NC = Need for Control; CSC = Cognitive
The highest bracket of household income (more than Self-Consciousness; Control = no diagnosis group; Oth.AD = Other
Anxiety disorder than GAD group; GAD = GAD group.
130.000 USD) was the most frequently reported level a
n = 43.
of income for the participating families. There was no b
n = 28.
association between group membership and gender. c
n = 22.
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8 ESBJØRN ET AL.
ESBJØRN ET AL.
other anxiety disorders. This finding is also in
accordance with the MCM of GAD (Wells, 1995) and
is consistent with results found in adult populations
(Cartwright-Hatton & Wells, 1997; Davis & Valentiner,
2000; Wells & Carter, 2001; Wells & Papageorgiou,
1998). However, these findings are only partially sup-
ported by previous studies of childhood and adolescent
samples. Two recent studies report elevated levels of
negative beliefs among clinical youth when compared to
nonclinical controls (Ellis & Hudson, 2011; Smith &
Hudson, 2013). However, differences between adoles-
cents with GAD and other types of anxiety became non-
significant after post hoc corrections were conducted
(Ellis & Hudson, 2011). Another study also reported
no significant differences in negative beliefs about worry
in youth with GAD, other types of anxiety, and nonan-
xious youth (Bacow et al., 2010).
Viewed in the light of these contrasting previous
findings, the current finding that children with GAD
endorse significantly more negative beliefs about worry
than children with other anxiety disorders is note-
worthy. Especially given that only 50% of our GAD
group presented with GAD as the primary diagnosis.
Ellis and Hudson (2011), as in the present study,
included children with GAD as any one of their
recorded diagnoses, whereas Bacow et al. (2010) cate-
gorized youth into five groups based on their primary
diagnosis. Our study thus lends even more support to
a MCM model of GAD in youth than previously
reported.
An additional explanation for the discrepancy in find-
ings may be the methodological differences in assess-
ment. Differences in assessment of beliefs about worry
may have affected the results. In most previous studies
that have included clinical samples (Bacow et al., 2010;
Bacow et al., 2009; Smith & Hudson, 2013), the Meta-
cognitions Questionnaire for Children (Bacow et al.,
2009) was employed. This instrument has obtained
satisfactory psychometric properties when assessed in
samples with a mean age of 11 years (Bacow et al.,
2010; Bacow et al., 2009); however, it has a poor internal
consistency for children 7 to 8 years of age (Smith &
Hudson, 2013). This may somewhat limit the findings
from previous studies that have included younger chil-
dren and highlights the need for further development
of psychometrically sound measures of metacognitions
in younger children.
The MCQ-C30, which was used in the present study,
has been reported to display adequate reliability in a
community sample of children aged 9 to 17 years of age
(Esbjørn et al., 2013), and our analyses of the internal
consistency for the 7- to 8-year-old children in the present
study suggests that the MCQ-C30 may be a better instru-
ment for younger children than the MCQ-C (as for
the MCQ-C30 vs. MCQ-C: POS, a = .73 vs. .46; NEG,
a = .71 vs. .64; CSC, a = .75 vs. .61; NC, a = .62 vs. .25;
Smith & Hudson, 2013).
Positive Metabeliefs
The present study also found that children with
GAD, but not other types of anxiety, endorsed signifi-
cantly more positive beliefs about worry than children
in the control group. This was incongruent with findings
from previous studies employing both youth and adult
samples, where no significant difference between patient
and nonpatient groups in positive beliefs about worry
have been reported (Bacow et al., 2010; Cartwright
et al., 2004; Cartwright-Hatton & Wells, 1997). Further-
more, one study of children (aged 8–13) who met criteria
for GAD found that they were not able to report on
positive aspects of worry, whereas 30.8% of nonanxious
children (aged 8–13) were able to endorse that worrying
has benefits (Muris et al., 1998). Our findings are, how-
ever, in line with two of the most recent studies of the
MCM in youth. In both studies, clinically anxious
children endorsed higher levels of positive beliefs than
nonclinical controls (Ellis & Hudson, 2011; Smith &
Hudson, 2013).
Cognitive confidence, need to control thoughts and
cognitive self-consciousness. Children with GAD, but
not other types of anxiety, also reported higher sco-
res on the cognitive confidence scale than nonclinical
controls, indicating lower levels of confidence. This is
partly consistent with the study by Ellis and Hudson
(2011), who reported no significant differences between
clinically anxious and nonanxious children. Other stu-
dies have not explored this aspect of metacognition, as
they have used the MCQ-C, which does not assess
cognitive confidence. Apart from differences regarding
positive and negative beliefs, we found that anxious
children, regardless of diagnosis, had higher levels of
metabeliefs about the need to control thoughts than non-
clinical controls. This finding is also in line with Ellis
and Hudson (2011), applying the MCQ-A (on which the
currently applied MCQ-C30 is based), but not with
studies applying the MCQ-C, where no differences
between the clinical and nonclinical groups were found
(Bacow et al., 2010; Smith & Hudson, 2013).
Finally, the current study found no significant
differences between any of the groups on cognitive
self-consciousness. This is consistent with results
from previous studies applying adult, adolescent, and
childhood samples (Cartwright-Hatton et al., 2004;
Cartwright-Hatton & Wells, 1997; Ellis & Hudson,
2011; Smith & Hudson, 2013) but inconsistent with
another study of a childhood sample (Bacow et al.,
2010). In the latter study, nonanxious youth were

METACOGNITIONS ININ CHILDREN
reported to have significantly higher levels of cognitive
monitoring compared to clinically anxious youth with
GAD and separation anxiety.
GENERAL DISCUSSION
The present studies aimed to assess the extent to which
children experience the same processes in worry and
GAD as have been found in adults. According to
Cartwright-Hatton and colleagues (2011), this is the
first step in extending an adult model of anxiety to
children. Previous studies of the MCM in childhood
and adolescent samples have provided only partial
support for the model (e.g., Bacow et al., 2010;
Cartwright-Hatton et al., 2004; Ellis & Hudson, 2011;
Matthews, Reynolds, & Derisley, 2006). Our results
offer the most substantive support for the applicability
of the metacognitive model of GAD (Wells, 1995) to
children as young as 7 years of age. The strongest
support comes from the role of negative worry beliefs.
Study 1 suggests that having negative beliefs about
worry is the metacognitive process that makes the
largest contribution to the variance in worry and
anxiety. Study 2 takes these findings a step further in
demonstrating that a significant difference between
anxious children with and without GAD is negative
worry beliefs. This is consistent with theory (Wells,
1995) and previous research (Cartwright-Hatton &
Wells, 1997; Davis & Valentiner, 2000; Wells & Carter,
2001; Wells & Papageorgiou, 1998).
According to the developmental psychopathology
paradigm, metacognitions are only pieces of a large and
complex puzzle that is the etiology of GAD (Kertz &
Woodruff-Borden, 2011; Rapee, 2001). Nonetheless,
focusing on the developmental mechanisms of anxiety
disorders may provide a useful way of understanding
present and previous findings from childhood samples.
Generally, elevated levels of positive metacognitions have
been reported when comparing clinical groups to nonan-
xious control groups. Two studies have reported elevated
levels when comparing clinically anxious children with
controls (Ellis & Hudson, 2011; Smith & Hudson,
2013), whereas our study found that only the GAD group
reported higher levels of positive beliefs compared to
nonclinical controls. Initially, these findings of higher
levels of positive metacognitions in clinical samples
compared to nonclinical samples may seem contradictory
to the findings regarding positive metacognitive beliefs
in adults populations (Cartwright-Hatton & Wells,
1997); however, a tentative developmental model of the
MCM is provided that may account for this difference.
As research within this field is still in its infancy, the
model can be no more than speculative, and further
research must be conducted to test its validity.
METACOGNITIONS
CHILDREN AND
AND ADOLESCENTS
ADOLESCENTS 153
9
We propose that as children develop sufficient
cognitive capacity for worry, some children will develop
higher levels of positive metacognitive beliefs than others.
Positive metabeliefs elicit higher levels of worry,
and worry is correlated with anxiety. We therefore
propose that these children will experience higher levels
of anxiety symptoms, albeit within the subclinical range.
In some cases anxiety may reach pathological levels,
which are then maintained by positive as well as negative
metabeliefs, especially in GAD.
Anxiety disorders are known to persist across time,
and the longer the anxiety disorder persists, the more
the child will suffer. Increased suffering may cause
the young person to reevaluate the usefulness of worry.
If worry is seen as potentially harmful, it may cause the
young person to reduce his or her positive metabeliefs to
the level of that seen in the nonclinical adult and
some adolescent populations (Cartwright-Hatton et al.,
2004). This would explain the lack of difference between
positive metabeliefs seen in adult populations (Cartwright-
Hatton & Wells, 1997). Thus, the presence of elevated
levels of positive metacognitive beliefs depends upon
the level of suffering experienced by the child and the
duration of the anxiety disorder.
Limitations
The current studies are not without limitations, and
these should be taken into account when interpreting
results. First, both studies are cross-sectional; therefore,
definitive conclusions about the etiology of GAD in
youth cannot be made. In addition, Study 1 had issues
with missing data. In Study 1, nearly half of the original
participants were eliminated from the study due to
incomplete items on questionnaires. However, Study 1
still offers a large, nationally representative sample
providing substantial power, justifying investigation of
the metacognitive model for GAD in children. The
sample size in Study 2 is limited, and firm conclusions
should not be drawn before the findings have been
replicated with a larger sample. Furthermore, the issues
of sample size made it impossible to breakdown the
Oth.AD groups into groups based on specific anxiety
diagnoses. However, we believe that the decision to
collect all non-GAD anxiety disorders into one group
was theoretically sound as the MCM (Wells, 1995) states
that key metacognitive processes distinguish GAD from
other anxiety disorders. Another limitation is that the
samples of our two studies differ in age span. Study 1
did not include younger children, whereas Study 2 did
not include adolescents. We did not assess children aged
7 and 8 in Study 1, as these would not have possessed
the required reading skills to complete the question-
naires independently. In Study 2, the questionnaires
were read out loud to the children who did not have
154
10 ESBJØRN
ESBJØRNETET
AL.
AL.
sufficient reading skills to read themselves. In the latter
study, we enrolled children who had been referred to a
research clinic for treatment. Only 7- to 13-year-old chil-
dren were eligible for treatment at the clinic, and we
were therefore not able to include adolescents. Although
some studies do not report age-related differences (e.g.,
Ellis & Hudson, 2011; Wilson & Hughes, 2011), we still
caution the reader against drawing firm conclusions
based on the present data before these have been
replicated in samples including the entire age range, as
metacognitions may develop in early childhood.
Furthermore, we did not control for worry content in
our studies, which may have affected our findings.
However, Bacow and colleagues (2010) applied a more
rigorous design controlling for worry content and did
not find differences between subsamples of children with
varying anxiety disorders. Nonetheless, one cannot
exclude the possibility that their findings were due to
secondary GAD diagnoses in the other anxiety sub-
groups. Despite this difference in sampling, and
although theory states that metabeliefs about worry
rather than worry content differentiates sufferers of
GAD from sufferers of other anxiety disorders, control-
ling for worry content may have provided different results
in our study.
Implications for Research, Policy, and Practice
Although studies are emerging assessing the MCM in
childhood and adolescent samples, further studies are
still warranted. The field would benefit from research
addressing the question of specificity of the MCM.
Including larger samples of children with other disor-
ders, for example, depressive or OCD symptoms would
allow for comparisons between these groups and GAD.
It would be useful to examine whether these disorders
share common maintaining processes or whether some
(particularly GAD) involve unique metacognitive pro-
cesses, as has been shown in certain adult studies (Wells
& Carter, 2001; Wells & Papageorgiou, 1998; Yilmaz
et al., 2008). In the future, longitudinal studies and inter-
vention designs involving even younger children, who
have yet to develop metacognitive beliefs, might illumi-
nate what, if any, casual role metacognitions have in the
development of GAD. Longitudinal studies would also
provide a means of testing the tentative developmental
model of the MCM. In addition, experimental designs
manipulating the levels of worry, or studies involving
samples with differing levels of disturbance (e.g., noncli-
nical, subclinical, outpatient, and inpatient) would allow
for further testing ofthe model. Finally, studies address-
ing the possible role of transmission of metacognitions
from parents to child will also increase our understand-
ing of the developmental mechanisms of metacognitive
beliefs and anxiety.
In summary, the current data support the extension
of the metacognitive model of GAD to children as
young as 7 years of age, and a tentative developmental
model of the MCM is provided. However, more
research is needed to increase our understanding of
the mechanisms of worry and GAD in children.
Nevertheless, the current results have important impli-
cations for the understanding and treatment of GAD
in children. First, an increased attention to elevated
levels of positive metabeliefs may be indicative of chil-
dren at risk for developing anxiety disorders, especially
in the presence of subclinical anxiety levels. Assessments
should be conducted using psychometrically sound
tools. Although tools are available, these need further
work to increase their validity and reliability among
young children; at present, the newly developed
MCQ-C30 provides the best internal consistency for
use with children ages 7 and 8 years. Finally, the findings
from existing studies of child and adolescent samples are
sufficiently encouraging for the development and testing
of Metacognitive Therapy for children with GAD.
FUNDING
The Egmont, Helse, Augustinus, and Simon Spies Foun-
dations provided financial support for the studies. We
thank the children and their families for participating in
this study. We also express our appreciation to all
staff that aided in assessment and administration of
measures.
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