Clin Child Fam Psychol Rev (2010) 13:151–163
DOI 10.1007/s10567-010-0065-0
The Metacognitive Model of Generalized Anxiety Disorder
in Children and Adolescents
Danielle M. Ellis • Jennifer L. Hudson
Published online: 30 March 2010
Springer Science+Business Media, LLC 2010
Abstract Worry is a common phenomenon in children and
adolescents, with some experiencing excessive worries that
cause significant distress and interference. The metacognitive model of generalized anxiety disorder (Wells 1995,
2009) was developed to explain cognitive processes associated with pathological worry in adults, particularly the role
of positive and negative beliefs about worry. This review
evaluates the application of the model in understanding child
and adolescent worry. Other key issues reviewed include the
link between cognitive and metacognitive development and
worry, and the measurement of worry and metacognitive
worry in young people. Implications of these findings and
directions for future research are discussed.
Keywords Cognition Metacognition Worry Anxiety Children Adolescents
Introduction
In recent years, there have been exciting new developments
in the understanding of worry in adult populations. Wells
(1995, 2009) developed the metacognitive model of generalized anxiety disorder (GAD), and this model focuses on
the role of metacognitive beliefs (i.e., thoughts about
thinking) in the development and maintenance of emotional
disorders. The metacognitive model will be discussed in
greater depth later in this review, but briefly, this model
suggests that positive beliefs about the benefits of worry
D. M. Ellis J. L. Hudson (&)
Department of Psychology, Centre for Emotional Health,
Macquarie University, Sydney, NSW 2109, Australia
e-mail: [email protected]
(e.g., ‘‘Worrying helps me cope’’) and negative beliefs about
the danger and uncontrollability of worry (e.g., ‘‘My worrying is bad for me’’) are associated with pathological worry.
This model has led to the development of new treatments for
pathological worry, with research suggesting that modifying
beliefs about worry enhances treatment outcome in anxietydisordered adults (Wells and King 2006).
Given the significance of the metacognitive model of
GAD in understanding worry in adult populations, this
review seeks to enhance an understanding of child and
adolescent worry through evaluating the applicability of
this model to children and adolescents. To address this
issue, this review is divided into six sections. The first
section provides a brief overview of features of worry in
child and adolescent populations. The second section provides an overview of the metacognitive model of GAD.
The third section evaluates the significance of cognitive
maturation in facilitating the capacity for worry and
developing beliefs about worry. The fourth section evaluates measures of child and adolescent worry, as adequate
assessment helps to better understand this phenomenon. In
the fifth section, evidence for the application of the metacognitive model of GAD in children and adolescents is
reviewed. Finally, the sixth section provides a summary of
the information and directions for future research.
A Brief Introduction to Worry
Worry has been described as ‘‘a chain of thoughts and
images, negatively affect-laden and relatively uncontrollable’’ (Borkovec et al. 1983, p. 10). Similarly, Vasey and
Daleiden (1994, p. 186) describe worry as ‘‘primarily an
anticipatory cognitive process involving repetitive, primarily verbal thoughts related to possible threatening
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outcomes and their potential consequences.’’ Research has
indicated that worry is a fairly common phenomenon in
children and adolescents (Henker et al. 1995). For example,
Muris et al. (1998) found that almost 70% of a sample of
8- to 13-year-old school children reported worrying ‘‘now
and then’’, as measured by an interview that inquired about
features of worry. Similarly, Muris et al. (2000) conducted
a worry interview, and they found that of school children
aged 4–12, 67.4% reported experiencing worry.
Yet, a proportion of young people will experience worry
that causes significant interference and distress in their
daily life. The Diagnostic and Statistical Manual of Mental
Disorders-Fourth Edition (DSM-IV; American Psychiatric
Association 1994) outlines uncontrollable and excessive
worry as the central defining feature of GAD. Point prevalence rates for GAD in children and adolescents have been
reported to range from 0.16% (Ford et al. 2003) to 11.1%
(Boyle et al. 1993). Children with GAD worry excessively
about a range of issues, including their health and that of
others, school, personal harm, their family, dying, what
others think, and broader social issues, such as homelessness (e.g., Muris et al. 2002b; Silverman et al. 1995;
Weems et al. 2000). Children with GAD tend to frequently
seek reassurance and ask multiple ‘‘What if…’’ questions
(Hudson et al. 2004).
Worry is also a feature of other anxiety disorders,
including separation anxiety disorder and social phobia
(Perrin and Last 1997; Weems et al. 2000). For example, a
child with separation anxiety disorder may worry about
losing or separating from his or her parent, and so may
have difficulties attending school or sleeping on his or her
own (Bernstein and Layne 2006). Despite the presence of
worry symptoms in other anxiety disorders, children and
adolescent with GAD report significantly greater worry
than youth with other anxiety disorders and youth without
psychopathology on the Penn State Worry Questionnaire
for Children (PSWQ-C; Chorpita et al. 1997).
Research suggests that excessive worry has a physiological impact on young people, including self-rated health
and doctor visits (Spruijt-Metz and Spruijt 1997). Symptoms of anxiety and excessive worry throughout adolescence are a risk factor for the development of anxiety
disorders in adulthood (Pine et al. 1998). Clinical worry is
also associated with risk of comorbidity with other anxiety
disorders and depression (Last et al. 1992; Masi et al.
1999). For example, Masi et al. (1999) found that of clinical youth aged from 7 to 18 diagnosed with GAD, 62%
also had a comorbid diagnosis of depression.
There are age-based differences in the presentation of
worry, with studies indicating that older children worry
more than younger children. For example, Vasey et al.
(1994) conducted a worry interview in a sample of nonclinical children aged 5–6, 8–9, and 11–12. They found
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that children of all ages reported worrying. However, in
comparison with 5- to 6-year-olds, the 8- to 9- and 11- to
12-year-olds worried about a greater range of issues, and
they elaborated more on their worries. Similarly, a study by
Henker et al. (1995) found that school students in grades 7
and 8 who completed a worry interview were more able to
provide detail to their worries in comparison with children
in grades 4 to 6. The older children were also more able to
elaborate on their worries, and these differences were not
due to advances in verbal fluency. Finally, a study by Muris
et al. (2000) found that school children aged from 7 to 12
reported a higher prevalence of worries (measured by a
worry interview), compared to children aged from 4 to 6.
There are also age-based differences in the presentation
of GAD and overanxious disorder (OAD), an earlier form
of GAD. Research suggests that the age of onset for OAD
ranges from 8.8 to 10 (Keller et al. 1992; Last et al. 1992),
with prevalence rates for this disorder increasing with age
(Strauss et al. 1988). Also, Strauss et al. (1988) found that
children aged from 12 to 19 who were diagnosed with
OAD had a greater number of OAD symptoms (e.g.,
excessive worry about future events) than children aged
from 5 to 11. Older children also had higher levels of selfreported anxiety and depression.
Research suggests that there are strong links between
worry and anxiety. For example, a study by Weems et al.
(2000) found that the number, intensity, and frequency of
worry were related to self-reported anxiety levels in a
sample of clinical youth aged from 6 to 16. Compared to
youth with specific phobias, worry experienced by youth
with GAD was linked to self-reported anxiety to a greater
extent. However, research in adult populations also suggests
that worry is partially independent from anxiety. Craske
(1999) suggests that worry is a closely associated consequence of anxious apprehension, and worry may be an
attempt to cope with anxiety. This is based on studies that
suggest that even though there are high correlations
between trait anxiety and worry (e.g., Tallis et al. 1992),
worry and anxiety also account for unique variance (Davey
et al. 1992). Craske (1999) also suggests there are psychophysiological differences between worry and anxiety such
that anxiety is associated with autonomic arousal, whereas
worry is associated with autonomic suppression. Finally,
cognitive processing may differentiate worry and anxiety.
Craske (1999) suggests that cognitive processing becomes
less elaborate as individuals’ transition from worrying about
possible future events, to anticipatory anxiety when these
events are imminent, to fear or panic when danger or threat
is present and cognitive activity is at a minimum.
According to Barlow (2002), worry may be a process
that is independent from anxiety. Worry may either be an
adaptive, or a failed, attempt to cope with threat or danger.
Depending on the intensity of the worry process, worry
Clin Child Fam Psychol Rev (2010) 13:151–163
may also be associated with chronic anxious apprehension.
Barlow (2002) also suggests that as anxiety increases and
becomes more chronic, so does worry, until pathological
levels of both are reached. At this point, worry becomes an
uncontrollable, problematic process that interferes with
performance and becomes the core feature of GAD. Worry
can also become the focus of anxious apprehension, which
is linked with meta-worry and reflected in the diagnostic
criteria for GAD. Given the prevalence of worry in children
and adolescents, and the interference associated with high
levels of worry, it is important that we understand the
factors that contribute to the development and maintenance
of worry. The following section evaluates the association
between beliefs about worry and worry symptoms so that
we can better understand this phenomenon.
The Role of Metacognition in Worry
Wells (2004) defined metacognition as ‘‘the cognitive processes, strategies, and knowledge that are involved in the
regulation and appraisal of thinking itself’’ (p. 167). Vasey
(1993, p. 23) suggests that metacognition ‘‘involves introspective knowledge about (1) one’s cognitive states and
abilities and their operation, and (2) strategies and procedures for effective problem solving’’, and is ‘‘the nonconscious operations of a central executive that organizes and
guides cognitive activity such as problem solving’’.
Increased awareness of the significance of metacognition
contributed to the development of the metacognitive theory
of GAD (Wells 1995, 2009). This model will be outlined,
before considering whether the cognitive processes, the
metacognitive model, describes are relevant for child and
adolescent worry.
The main focus of the model has been on the metacognitive factors associated with pathological worry in
adults with GAD. Wells (1995, 2009) hypothesized that
worry is maintained by metacognitive beliefs concerning
the benefits and dangers of worrying. Initially, worry is
triggered as a coping response by an intrusive thought (e.g.,
‘‘What if I get cancer?’’) and is primarily focused on a
range of issues including physical health, social, or financial concerns. This is known as Type 1 worrying. Positive
metacognitive beliefs are linked to the usefulness of worry
as a coping strategy, and these beliefs include ‘‘Worrying
helps me cope’’ or ‘‘If I worry I’ll be prepared’’. Wells
(1995, 2009) suggests that positive beliefs about worry are
normal and should be observed in clinical and non-clinical
populations.
Individuals with GAD are differentiated by the activation of negative beliefs about worry, specifically the
uncontrollability (e.g., ‘‘My worrying thoughts persist, no
matter how I try to stop them’’) and the danger (e.g.,
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‘‘Worrying will make me go crazy’’) of worry. The activation of these beliefs contributes to negative appraisals of
worry, including worrying about worry, which is known as
Type 2 worry or meta-worry. Negative emotions associated
with meta-worry, such as increased anxiety, make it
increasingly difficult for the individual to recognize that it is
safe to stop worrying. These increases in anxiety may occur
in the form of a panic attack, and they reinforce negative
beliefs about worry and the need to continue worrying.
According to Wells (1995, 2009), Type 2 worry contributes to two feedback cycles that maintain the worry
process. First, behaviors such as reassurance seeking or
avoidance of cues that trigger worry maintain negative
beliefs about the danger and uncontrollability of worry.
This is because the individual relies on external information to control their thoughts, they miss out on opportunities to learn that worrying is controllable and harmless, and
they are prevented from learning more adaptive coping
strategies. The second feedback cycle relates to thought
control strategies, such as suppression of thoughts that
trigger worry. Thought-control strategies are hypothesized
to actually increase the number of thought intrusions and
reinforce the belief that worry is uncontrollable. There is
also a failure to interrupt the worry process.
A growing body of evidence supports several key
aspects of the metacognitive model of GAD in adult populations (for a review, see Wells 2004). This includes the
hypothesized link between positive beliefs about worry
and level of worry, and the finding that individuals with
GAD, other anxiety disorders, and non-clinical controls
endorse similar levels of positive beliefs about worry (e.g.,
Cartwright-Hatton and Wells 1997; Wells and Papageorgiou 1998). Research has also found that adults with GAD
report a greater need to control their worry and/or a belief
that their worry was uncontrollable in comparison with
adults with other anxiety disorders and adults without
anxiety disorders (non-clinical controls). Negative beliefs
about worry are a better predictor of pathological worry
than the frequency or content of worry (e.g., CartwrightHatton and Wells 1997; Davis and Valentiner 2000; Wells
and Carter 2001; Wells and Papageorgiou 1998). Research
also suggests that worry has several negative consequences, including difficulties in self-regulation of cognition and emotion (e.g., Borkovec et al. 1983; Wells and
Carter 1999; Wells and Papageorgiou 1995). Worrying
may increase negative thinking and thought intrusions
and block emotional processing following stress (e.g.,
Borkovec et al. 1983; Wells and Carter 1999; Wells and
Papageorgiou 1995). These difficulties in self-regulation
may in turn reinforce negative beliefs about worry and
meta-worry.
The research and theoretical developments that have
occurred since the metacognitive model of GAD was first
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introduced have led to the expansion of the model to address
the role of metacognitive beliefs across several different
disorders (Baker and Morrison 1998; Papageorgiou and
Wells 1998; Wells 2007, 2009). This includes obsessive–
compulsive disorder (OCD), social phobia, post-traumatic
stress disorder, hypochondriasis, and auditory hallucinations. The metacognitive model has also been developed to
address the role of metacognitive beliefs in depression
(Papageorgiou and Wells 2001). The model suggests that
depressed mood is associated with the activation of positive beliefs about rumination, including the usefulness of
rumination as a coping strategy (Papageorgiou and Wells
2001). For example, the individual may believe ‘‘If I dwell
on my past mistakes, I can be a better person’’. However,
an over-reliance on rumination as a coping strategy activates negative beliefs about the uncontrollability and
danger of rumination, such as ‘‘It’s impossible to stop
myself from ruminating’’, which reinforces feelings of
helplessness and depression. Research has found support
for this model in adult populations (Papageorgiou 2006).
Given these important developments in understanding
worry in adults, it is possible that the metacognitive model
of GAD can be applied downward to better understand
worry in child and adolescent populations. Before examining evidence for the metacognitive model in young
people, the following section will explore the link between
cognitive maturation and the development of worry and
beliefs about worry.
Cognitive and Metacognitive Development and Worry
Cognitive Development and Worry
Vasey (1993) suggests that two cognitive abilities are
required in order for an individual to worry. The first
cognitive ability is the capacity to anticipate future events.
It is unclear the extent to which an individual needs to
anticipate the future to be able to engage in worry, although
it is possible that only vague ideas about the possibility of
threat are required. This suggests that even very young
children are capable of worrying. The second cognitive
ability is the capacity to go beyond what is directly
observable and elaborate on catastrophic possibilities. This
ability is thought to increase as the child develops, which in
turn may increase the capacity for worry. Bases on Piaget’s
theory of cognitive development (Piaget 1970), Vasey
(1993) suggest that young children (i.e., before 7–8 years)
have only a vague ability to predict the future. In addition,
young children are likely to be able to consider only one
solution to a problem and view it as the only solution.
During middle childhood, the ability to predict future
outcomes becomes more complex, and children can
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consider a range of different possibilities using deductive
reasoning. By adolescence, with increasingly abstract
thinking, there is the capacity to consider potential multiple
negative outcomes. The adolescent also has the capacity to
elaborate on these possible outcomes. This suggests that
the capacity for worry increases with cognitive development. In terms of when the capacity for worry begins,
Vasey (1993) suggests that an individual may need to
anticipate only one threatening possibility for worry to
occur, which means that even preschool-aged children may
have the cognitive capacity to worry.
The hypothesized relationship between cognitive maturation and worry is supported by a study conducted by
Muris et al. (2002a). They explored the relationship
between cognitive development and anxiety in a sample of
normal school children and children with below-average
intellectual abilities, who were aged from 4 to 13. An
anxiety interview was conducted to assess for topics that
the children worried about, in addition to a Piaget conservation task that measured cognitive development. They
found that children of all ages reported having fears and
worries, but fears and worries were more prevalent in
children who passed the conservation task. This suggests
that stage of cognitive development is associated with
increased levels of worry and anxiety. An additional study
by Muris et al. (2002b), which included normal school
children aged from 3 to 14, found similar results.
In sum, these findings suggest that cognitive maturation
may allow for an increased ability to predict and elaborate on
possible threatening outcomes, which in turn may be associated with an increased capacity for worry. However, cognitive maturation alone cannot account for the development
of pathological worry. The relationship between cognitive
maturation and metacognition will now be considered.
Metacognitive Development and Worry
Research in a variety of areas (e.g., intellect, memory, selfconcept, scientific thinking) suggests that as children
develop, they are increasingly capable of metacognitive
thinking (Kuhn 1999, 2000a, b, c; Vasey and Daleiden
1994). This includes enhanced abilities to monitor, plan,
and self-regulate their behavior (Vasey 1993). Research
suggests that the capacity to think about one’s own
thoughts may start to develop at a very young age. For
example, much research has been conducted on the
development of theory-of-mind (TOM), which is the ability
to attribute mental states (e.g., thoughts, beliefs, intents,
desires, pretending, knowledge) to oneself and others
(Flavell 1999). Theory-of-mind also relates to the ability to
understand that others have beliefs, desires, and intentions
that are different from one’s own (Flavell 1999). Research
on TOM has shown that by 3 years of age, children have
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some awareness of themselves and others as knowers (for a
review, see Kuhn 2000b). They also have some awareness
of the existence of thinking as a mental activity that they
and others experience (for a review, see Flavell et al.
1995). From 4 years of age, children increasingly show a
capacity for understanding false beliefs, and they are able
to report on their own mental activity (for a review, see
Flavell 1999; Kuhn 2000b). This indicates that there is an
ability to comprehend the concept of the mind.
Several studies demonstrate this ability in young people.
For example, Flavell et al. (2000) administered a thinking
task to 5- and 8-year-old school students, as well as adults
recruited from universities. This task tested the individual’s
ability to report on his or her own thoughts when guided to
do so. Flavell et al. (2000) found that during an interview,
5-year-old children were able to report awareness of their
own thoughts. However, the awareness of the 8-year-old
children and adults was more advanced, in that they were
better able to report on their introspective thoughts. Flavell
et al. (1998) explored the extent to which children and
adults understood that thoughts are uncontrollable. Their
sample included school students who were 5, 9, and
13 years old, in addition to adults recruited from universities. These participants read several stories designed to
illustrate that individuals experience thoughts even if they
do not want to and try not to. Interviews were then conducted to assess the extent to which participants recognized
that thoughts could be uncontrollable. Flavell et al. (1998)
found that 5-year-olds were unable to understand that
thoughts could be difficult to control, although by 9 years
of age, there was an emerging awareness of this, and by
adolescence and adulthood, there was full awareness that
thoughts could be difficult to control.
As a whole, this research suggests that even young
children are capable of forming beliefs about their
thoughts, although increased cognitive development may
enhance this ability. The next question to consider is
whether worry and beliefs about worry can be validly and
reliably measured in child and adolescent populations,
given the unique cognitive, social, and emotional abilities
of this age group (Vasey 1993). Research that examines
this issue will now be reviewed in the following section.
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assessment is necessary for understanding worry in child and
adolescent populations. As worry is an internal experience, it
may be difficult for parents to report on this phenomenon,
and so adequate self-report measures are needed so that
children and adolescents can report on their own symptoms.
A number of measures have been developed that assess
childhood fears and anxiety, and some of these measures
include subscales that specifically measure worry. For
example, the Revised Children’s Manifest Anxiety Scale
(RCMAS; Reynolds and Richmond 1978) was designed for
children in grades 1 to 12, and it includes a subscale
measuring Worry/Oversensitivity. The Worry/Oversensitivity subscale was designed to assess the content of worrisome thoughts, and items on this subscale include
‘‘I worry about what is going to happen’’ and ‘‘I worry
when I go to bed at night’’. Although the RCMAS has been
shown to have good convergent validity and test–retest
reliability, research has also shown that the RCMAS has
poor discriminant validity across different psychological
disorders (for a review, see Schniering et al. 2000). Also,
many studies using the RCMAS frequently report total
anxiety scores only, which limits the ability to draw conclusions about worry symptoms specifically.
Other self-report measures developed for assessing child
and adolescent anxiety include the Screen for Child Anxiety and Related Disorders (SCARED; Birmaher et al.
1997), the Multidimensional Anxiety Scale for Children
(MASC; March 1997), and the Spence Children’s Anxiety
Scale (SCAS; Spence 1997). These measures have been
designed to assess for GAD symptoms according to DSMIV (American Psychiatric Association 1994) criteria in
children aged between 8 and 18. For example, items from
the SCAS GAD scale include ‘‘I worry about things’’ and
‘‘When I have a problem, I feel shaky’’. These measures
provide valid and reliable measures of anxiety symptoms,
as research has shown that they have good internal consistency, convergent and divergent validity, discriminant
validity, and test–retest reliability (for a review, see
Schniering et al. 2000). However, they have not been
designed to specifically measure features of worry, such as
the content, frequency or severity of worry, or cognitive
processes that are hypothesized to contribute to worry.
Measures of Worry
Measures of Worry
Measures of Anxiety and Fears
Given that research suggests that even young children have
awareness of their own thoughts (Flavell et al. 2000), and
children as young as 9 years old can report that their worries
are difficult to control (Flavell et al. 1998), adequate
The most widely used measure of child and adolescent
worry is the PSWQ-C, which assesses for the severity,
excessiveness, and uncontrollability of worry in children
aged from 6 to 18 (e.g., ‘‘My worries really bother me’’).
The PSWQ-C was adapted from the Penn State Worry
Questionnaire (PSWQ; Meyer et al. 1990), which is an adult
version of the measure. The child version consists of 14
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items has a second-grade reading level and was developed
using a sample of children from grades 2 to 12. Research
has shown that the PSWQ-C consists of a unitary factor and
it has good internal consistency (alpha = .89; Chorpita
et al. 1997). Good discriminant and convergent validity has
also been found (i.e., high correlations with self-report and
interview measures of worry and uncontrollability), and a
1-week test–retest reliability coefficient of .92 was reported
in a clinical sample (Chorpita et al. 1997).
There are several other measures of worry in children,
although these measures are less widely used. The Worry
Scale (Perrin and Last 1997) is a 31-item self-report
measure of the content of worrisome thoughts in children
(e.g., ‘‘I worry about bad things happening to me’’). The
measure was developed using a sample of anxiety-disordered, attention deficit hyperactivity disordered, and nonclinical youth aged from 5 to 13 . The Worry Scale was
shown to have good internal consistency (alpha = .93 for
anxious children; Perrin and Last 1997). Convergent
validity was also demonstrated, as The Worry Scale correlated with several self-report measures of child anxiety,
including the RCMAS (Perrin and Last 1997).
The Why Worry Questionnaire (WWQ; Freeston et al.
1994) consists of 19 items that assess incorrect beliefs
associated with worry. The measure was developed using a
sample of non-clinical adults. Two factors have been
identified that assess the belief that worries help prevent
negative events or to avoid the worst, and worries help find
better ways of doing things by increasing control and
helping find solutions. Although this is an instrument
developed to assess adult worry, it has been used in adolescent samples. In a sample of non-clinical youth in grades
7 to 11, the WWQ exhibited good internal consistency
(alpha = .88; Gosselin et al. 2007b). Convergent validity
has also been demonstrated as the WWQ correlated with
the PSWQ-C (Gosselin et al. 2007b). A 25-item revised
version of this measure, The Why Worry-II (WW-II;
Gosselin et al. 2007a), measures five types of beliefs: (1)
Worry aids problem solving, (2) Worry is a source of
motivation, (3) Worry prevents negative emotions, (4)
Worry prevents negative outcomes, and (5) Worry is a
positive personality trait. The WW-II has been shown to
have good internal consistency (alpha = .90) and adequate
convergent validity, as it correlated with the PSWQ-C in a
sample of school students aged from 14 to 18 (Laugesen
et al. 2003).
Finally, The Worry Scale for Children (WSC; Muris
et al. 1998) was developed specifically for a study conducted by Muris et al. (1998) using a non-clinical sample
of youth aged from 8 to 13. It consists of 40 items that ask
about the content of worry (e.g., ‘‘I worry about falling
ill’’). The WSC has been shown to have good internal
consistency (alpha = .88) and convergent validity, as it
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correlated with measures of anxiety and depression (Muris
et al. 1998). Additional studies have not evaluated the
psychometric properties of this measure.
Measures of Metacognitive Beliefs About Worry
Two measures have been developed that assess for beliefs
about worry in child and adolescent populations. The
Meta-cognitions Questionnaire for Adolescents (MCQ-A;
Cartwright-Hatton et al. 2004) is a 30-item measure of
beliefs about worry that was developed using a sample of
school students aged from 13 to 17. The MCQ-A is based
on an adult version of the measure, the Meta-Cognitions
Questionnaire—30 (Wells and Cartwright-Hatton 2004),
which itself is a shortened version of the Meta-Cognitions
Questionnaire (Cartwright-Hatton and Wells 1997). The
first two subscales of the MCQ-A measure core features of
the metacognitive model of GAD (Wells 1995, 2009).
Subscale 1 measures positive beliefs about worry, in that
worry helps in planning and problem solving and is a
positive characteristic (e.g., ‘‘Worrying helps me cope’’).
Subscale 2 measures negative beliefs about the danger and
uncontrollability of thoughts, including the belief that
worry has to be controlled to ensure safety and the ability
to function, (e.g., ‘‘My worrying is dangerous for me’’).
The remaining three subscales measure other aspects of
metacognition that are thought to relate to intrusive
thoughts. Subscale 3 measures cognitive confidence, or
lack of confidence in memory and attentional capacities
(e.g., ‘‘I have a poor memory’’). Subscale 4 measures
negative beliefs about thoughts in general, including
themes of superstition, punishment, and responsibility
(e.g., ‘‘I should be in control of my thoughts all of the
time’’). Finally, subscale 5 measures cognitive selfconsciousness, which is the preoccupation that one has
with their thought processes (e.g., ‘‘I am constantly aware
of my thinking’’).
Cartwright-Hatton et al. (2004) found that adolescents
endorsed the full range of metacognitive beliefs, including
positive and negative beliefs about worry. The extent to
which these metacognitive beliefs were endorsed did not
increase with age, suggesting that these concepts were
nearly fully formed by the age of 13. Regarding the
psychometric properties of the MCQ-A, internal consistency was good, with Cronbach’s alpha ranging from .66 to
.91. The MCQ-A also had good convergent validity, as
increased endorsement of metacognition was positively
associated with self-reported symptoms of anxiety,
depression, and obsessionality. Finally, the MCQ-A had
good discriminant validity, as scores differentiate a sample
of clinical and non-clinical youth. However, the clinical
sample in this study was quite small (n = 11) and control
participants did not undergo diagnostic assessment to
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ensure they did not meet criteria for an emotional disorder.
This suggests that replication of this research in a larger
clinical population is warranted so that we can better
evaluate differences between clinical and non-clinical
participants, in addition to evaluating the reliability and
validity of the MCQ-A in anxiety-disordered youth.
The Metacognitions Questionnaire for Children (MCQC; Bacow et al. 2009) is a 24-item measure of metacognition in children and adolescents that was developed using
a sample of clinically anxious and non-clinical participants
aged from 7 to 17. This measure is based on the MCQ-A
but it was modified to evaluate the following metacognitive
beliefs across a broader age range: (1) Positive beliefs
about worry, (2) Negative beliefs about worry, (3) Superstitious, punishment, and responsibility beliefs, and (4)
Cognitive monitoring. Children and adolescents were
found to endorse the full range of metacognitive beliefs on
the MCQ-C, including positive and negative beliefs about
worry. Internal consistency for this measure was good, with
Cronbach’s alpha ranging from .64 to .87. Convergent
validity was also demonstrated, with each subscale of the
MCQ-C significantly correlating with symptoms of worry
and depression in this sample. This study also found that
girls scored higher than boys on total metacognition, and
there were age-based differences in cognitive monitoring,
with older children scoring higher than younger children.
The non-clinical group used in this study was quite small in
comparison with the clinical sample, and 60% of the
control sample had sub-clinical symptoms of one or more
psychological disorders limiting the conclusions that can
be drawn from the study.
phenomenon. Finally, except for the PSWQ-C, no studies
have administered these measures to young people with
and without GAD making it difficult to determine the
unique features of worry in children and adolescents with
GAD. Research into measures of worry needs to continue
so that we better understand this phenomenon in young
people, and the age in which worry can be reliably and
validly measured. The following section will now review
evidence that examines the applicability of the metacognitive model of GAD to child and adolescent populations.
Issues in the Measurement of Worry
Research in adult populations suggests that endorsement of
positive beliefs about worry is linked with worry level
(Wells 2004). The findings of studies conducted in child and
adolescent populations are consistent with this research.
Laugesen et al. (2003) found that, in a sample of school
students aged from 14 to 18, positive beliefs about worry
(measured by the WW-II) increased as worry level (measured by the PSWQ-C) increased. Barahmand (2008) conducted a study on school students aged from 16 and 19 and
found that positive beliefs about worry (measured by the
WW-II) were positively associated with worry and anxiety.
Similarly, a study by Gosselin et al. (2007a, b) found that in
a sample of school students aged from 12 to 19, beliefs
regarding the usefulness of worry (measured by the WWQ)
were positively correlated with worry level (measured by
the PSWQ-C). This included the belief that worry helps to
solve problems and worry helps avoid the worst.
There is mixed evidence for the hypothesis that positive
beliefs about worry are normal in young people with and
without pathological worry. Muris et al. (1998) found that
school children aged from 8 to 13 who met criteria for
In summary, several measures have been developed that
assess for different aspects of child and adolescent worry.
This includes measures that assess for the content, severity,
excessiveness, and uncontrollability of worry, as well as
positive and negative beliefs about worry. Research conducted so far supports the use of these measures in
assessing for worry and beliefs about worry, although there
may be benefits to ongoing research in this area. First,
some of these measures are based on adult concepts of
worry, including the PSWQ-C, MCQ-A, and WWQ.
Further research may be required to ensure that these
measures accurately measure worry in young people.
Second, despite the potential of the MCQ-A in measuring
child and adolescent metacognition, the psychometric
properties of this measure have not yet been evaluated in a
large clinical population. Third, several measures of child
and adolescent worry have only limited research on their
psychometric properties. Fourth, it is unclear how the
development of worry may affect the assessment of this
The Metacognitive Model of GAD in Children
and Adolescents
Evaluating the Model in Child and Adolescent
Populations
The appropriateness of the metacognitive model in understanding child and adolescent worry will be reviewed in
terms of evidence that does or does not support predictions
of the model. Specifically, research will be reviewed to
determine whether both clinical and non-clinical youth
report equal levels of positive beliefs about worry, and
whether young people with high levels of worry are more
likely to have negative beliefs about worry compared to
young people with low levels of worry. Evidence for the
existence of feedback cycles that are hypothesized to
maintain the worry process will also be examined.
Positive Beliefs About Worry
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158
OAD/GAD were unable to report on positive features of
their worry (measured by a worry interview), in comparison with 30% of control children who did not meet diagnostic criteria and were able to report some positive
features. In contrast, Cartwright-Hatton et al. (2004) found
that there were no significant differences between clinical
and control groups on positive beliefs about worry (measured by the MCQ-A) in a sample of school students aged
from 13 to 17. Bacow et al. (2009) found similar results
in a sample of anxiety-disordered and non-clinical youth
aged from 7 to 17 who completed the MCQ-C. Finally,
Laugesen et al. (2003) found that ‘‘moderate’’ worriers
(children scoring between the 40 and 60th percentiles on
the PSWQ-C) and ‘‘high’’ worriers (children scoring at or
above the 80th percentile on the PSWQ-C) reported similar
levels of positive beliefs about worry (measured by the
WW-II).
Negative Beliefs About Worry
Wells (1995, 2009) suggests that it is the activation of negative beliefs about the uncontrollability and danger of worry
that uniquely contributes to the development and maintenance of pathological worry in GAD. Consistent with this,
Cartwright-Hatton et al. (2004) found that clinical youth with
an anxiety disorder reported significantly higher levels of
negative beliefs about worry (measured by the MCQ-A)
compared to non-clinical youth. In contrast, Bacow et al.
(2009) found that there were no significant differences
between clinically anxious and non-clinical participants in
negative beliefs about worry (measured by the MCQ-C).
However, as previously discussed, the non-clinical group
used in this study was quite small in comparison with the
clinical sample, and a large proportion of the control sample
had sub-clinical symptoms of one or more psychological
disorders. This may have impacted on the ability to detect
differences between groups. At the present time, no research
has evaluated negative beliefs about worry in adolescents
with different emotional disorders.
Additional research has found that children and adolescents with high levels of worry report more negative beliefs
about their worry. For example, Muris et al. (1998) found
children aged 8 to 13 who met criteria for OAD/GAD were
more likely to report that their worry was difficult to control
(measured by a worry interview) in comparison with children who did not meet criteria for OAD/GAD. Studies have
also found that young people with clinical worry identify
their worries as being intense, in terms of how much they
worry about a specific issue. In a study by Weems et al.
(2000), anxiety-disordered youth aged from 6 to 16 diagnosed with GAD rated their worry as more intense (measured by a worry interview) than youth diagnosed with
specific phobias. Similarly, Perrin and Last (1997) found
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Clin Child Fam Psychol Rev (2010) 13:151–163
that anxiety-disordered youth aged from 5 to 13 rated their
worries as more intense (measured by The Worry Scale) in
comparison with normal controls. Yet, there is considerable
overlap between the ‘negative beliefs about worry’ component of the metacognitive model and symptoms of GAD
according to DSM-IV (American Psychiatric Association
1994). Excessive and uncontrollable worry is one of the
core diagnostic features of GAD, and to some extent, this
research simply confirms that young people with high levels
of worry experience uncontrollable worry.
Behavior Feedback Cycle
According to the metacognitive model of GAD, metaworry is reinforced by certain behaviors, including seeking
excessive levels of reassurance from others and avoiding
situations that may trigger worry (Wells 1995, 2009).
Research suggests that these behavioral responses may
exist in child and adolescent populations. Masi et al. (1999)
found that in a sample of 7- to 18-year-olds diagnosed with
GAD, 83% reported a need for reassurance (measured by a
clinical interview). There is also evidence that young
people avoid worry-provoking triggers. For example,
Bernstein (1991) found that in a sample of 7- to 17-yearolds who were referred to a school refusal clinical for
treatment, school refusal was positively associated with
pathological worry (measured by a clinical interview).
Thought Control Feedback Cycle
The metacognitive model hypothesizes that individuals
with clinical levels of worry will rely on thought control
strategies to manage their worry, particularly thought
suppression (Wells 2009). Wells (2004) suggests that this
strategy is usually ineffective, which reinforces negative
beliefs about the uncontrollability of worry. There is mixed
support for this hypothesis in young people. Gosselin et al.
(2007a, b) grouped school students aged from 12 to 19 into
those experiencing ‘‘moderate’’ levels of worry (children
scoring between the 40 and 60th percentiles on the PSWQ),
and those classified as having ‘‘high’’ levels of worry
(children scoring at or above the 80th percentile on the
PSWQ). Those children classed as having high levels of
worry used more avoidance strategies (measured by the
Cognitive Avoidance Questionnaire, CAQ; Gosselin et al.
2002) than those classed as having moderate levels of
worry. This included thought suppression, although a
stronger relationship was found for thought substitution
and avoidance of stimuli that triggered unpleasant
thoughts. However, Laugesen et al. (2003) failed to find
any link between worry and thought suppression (measured
by the White Bear Suppression Inventory (WBSI; Wegner
and Zanakos 1994)). In some preliminary research on
Clin Child Fam Psychol Rev (2010) 13:151–163
youth with post-traumatic stress disorder (PTSD), the
degree of thought suppression significantly predicts later
PTSD (Ehlers et al. 2003; Aaron et al. 1999).
It is possible that the mixed findings regarding thought
suppression might be due to these studies using different
measures of this phenomenon. At the present time, no further research has been undertaken to clarify this issue, and it
is unclear what impact thought suppression has on worry
levels in children and adolescents. It is also unclear whether
young people make any attempts to interrupt the worry
process, although Muris et al. (1998) found that school
children meeting criteria for OAD/GAD reported that they
were less likely to engage in activities that distracted them
from their worries (measured by a worry interview) in
comparison with control children. Farrell and Barrett (2006)
conducted a study looking at developmental differences in
the cognitive processing of threat in OCD in a sample of
children and adolescents (6–17 years) and adults seeking
treatment for OCD. Using the WBSI, they found that children reported significantly less thought suppression in
comparison with adults, but there were no differences
between children and adolescents on thought suppression.
Emotion Feedback Cycle
Wells (1995, 2009) suggests that negative emotions associated with meta-worry, such as increased anxiety, make it
difficult for the individual to recognize that it is safe to stop
worrying. These negative emotions are hypothesized to
reinforce negative beliefs about worry and the need to
continue worrying. As previously discussed, research has
supported the link between negative beliefs about worry
and symptoms of worry and anxiety, and also between
negative beliefs about worry, depression, and obsessionality in clinical and non-clinical youth aged from 7 to 17
(Bacow et al. 2009; Cartwright-Hatton et al. 2004; Mather
and Cartwright-Hatton 2004; Matthews et al. 2007). This
research suggests that the more negative beliefs a young
person has about their worry, the more negative emotions
they may experience. This in turn may potentially reinforce
negative beliefs about worry while reinforcing positive
beliefs regarding the benefits of worry, due to a belief that
it is not safe to stop worrying. As the existing research
proves only that there are associations between beliefs
about worry and negative emotions, longitudinal studies
are required to determine the direction of this relationship.
159
support for extending the metacognitive model of GAD
downwards to child and adolescent populations. The
majority of studies suggest that endorsement of positive
beliefs about worry is normal in youth who have normal
and high levels of worry. However, the results have been
mixed when comparing clinical and non-clinical youth on
negative beliefs about worry. Some research suggests that
clinical youth report more negative beliefs about worry
compared to non-clinical controls (Cartwright-Hatton et al.
2004), while other research suggests that there are no differences between these groups (Bacow et al. 2009). At the
present time, no research has compared beliefs about worry
in youth with GAD compared to youth with another anxiety disorder and non-clinical controls.
Research thus far has also found mixed results regarding
age and gender differences in endorsement of metacognition. Cartwright-Hatton et al. (2004) showed no age- or
gender-based differences in metacognition, yet Bacow
et al. (2009) demonstrated differences in metacognition
based on both age and gender. Finally, research supports
the existence of behavioral and emotion feedback cycles
that Wells (1995, 2009) suggests maintain the worry process but the cyclical nature has yet to be demonstrated.
Mixed findings exist regarding the thought control feedback cycle. Some studies have found that increased worry
is associated with thought avoidance strategies (Gosselin
et al. 2007a, b), while other research suggests that there is
no relationship between thought suppression and worry
(Laugesen et al. 2003).
A number of methodological concerns hamper an ability
to better understand the role of metacognition in child and
adolescent worry. Many of the studies reviewed here used
different measures that assessed different features of worry.
This included the use of self-report measures of either the
content of worry or beliefs about worry, or the use of nonstandardized clinical interviews. Future research may
benefit from using reliable and valid measures of the
excessiveness and severity of worry (e.g., the PSWQ-C), in
addition to measures that have been specifically designed
to assess for the metacognitive beliefs of children and
adolescents (e.g., the MCQ-A or MCQ-C).
Conclusions and Future Directions
Ongoing Evaluation of the Metacognitive Model
of GAD in Child and Adolescent Populations
Directions for Future Research
To summarize, research suggests that children as young as
7 years of age endorse both positive and negative beliefs
about worry, and endorsement of these beliefs are positively associated with emotional symptoms. There is partial
The metacognitive model of GAD in adult populations has
proved helpful in enhancing an understanding of the cognitive processes associated with pathological worry, and
emerging research supports the downward extension of
this model to understand worry in child and adolescent
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160
populations. However, methodological differences between
studies have limited conclusions regarding the role of
metacognition in child and adolescent worry. To evaluate
the metacognitive model of GAD more comprehensively,
future research may benefit from comparing the metacognitive beliefs of children and adolescents with different
emotional disorders. Specifically, it may be of benefit to
conduct research where the metacognitive beliefs of youth
with GAD are evaluated in comparison with the beliefs of
youth with another anxiety disorder and non-clinical controls. Based on metacognitive theory, it would be expected
that there will be no differences between these groups on
positive beliefs about worry, but youth with GAD will
score higher on negative beliefs about worry in comparison
with youth with other anxiety disorders and non-clinical
controls.
It may also be of benefit to conduct future research on
beliefs about worry in anxious children and adolescents
who have comorbid depression, to determine whether the
metacognitive model can be applied to this population.
There are high levels of comorbidity between anxiety and
depression (Last et al. 1992; Masi et al. 1999), and research
in adult populations has suggested that metacognitive
beliefs about rumination are associated with depressive
symptoms (Wells 2009). Thus, it may be interesting to
compare the metacognitive beliefs of anxious/depressed
children and adolescents in comparison with anxious and
non-clinical youth. This may help evaluate whether beliefs
about worry are associated with emotional symptoms in
anxious/depressed youth, and whether there are differences
in metacognitive beliefs between these groups.
To evaluate whether metacognitive processes contribute
to the development and maintenance of depression symptoms in young people, future research may benefit from
examining the role of positive and negative beliefs about
depressive rumination in children and adolescents. The
downward extension of the metacognitive model proposed
by Papageorgiou and Wells (2001) may enhance an
understanding of factors that are significant in adolescent
depression. Thus, it may be interesting to determine whether depressed adolescents endorse positive and negative
beliefs about rumination, and whether these beliefs are
associated with emotional symptoms. It may also be
interesting to compare the metacognitive beliefs about
rumination of depressed adolescents to adolescents with
other emotional disorders and non-clinical controls, to
determine whether there are any differences between these
groups. However, at the present time, no research has been
conducted on this issue in child and adolescent populations.
Research may also benefit from an examination of the
metacognitive beliefs of children younger than 12 years.
Although Bacow et al. (2009) examined the metacognitive
beliefs of children as young as 7 years of age using the
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Clin Child Fam Psychol Rev (2010) 13:151–163
MCQ-C, the conclusions that can be drawn from this study
are hampered because of methodological concerns. Thus,
further research on the metacognitive beliefs of younger
children would be of benefit. One potential area for
research includes the extent to which young children
actually have metacognitive beliefs about worry. A limitation of the MCQ-C and MCQ-A is that participants are
required to indicate the degree to which they agree or
disagree with a particular statement. Qualitative research
may help explore in an open-ended manner whether
younger children understand the questions being asked of
them.
Studies have shown that children as young as 4 years of
age report worrying (Muris et al. 2000) and so if it is
determined that young children do in fact have metacognitive beliefs about worry, it would be interesting to
determine at what age these beliefs develop. Research on
metacognition in a younger age group may also help
evaluate whether there is a sequential process to the
acquisition of metacognitive beliefs, such that positive
beliefs about worry develop before negative beliefs, or vice
versa. It may also be possible that positive and negative
beliefs about worry develop simultaneously.
Research may also examine the relationship between
cognitive development and metacognitive beliefs about
worry in children and adolescents. Similar to the study
conducted by Muris et al. (2002b), children and adolescents
may complete measures of metacognition in addition to a
Piaget conservation task. This may help determine whether
cognitive development is associated with increased metacognitive beliefs and worry.
Regarding the behavior, thought, and emotion, feedback
cycles that Wells (1995, 2009) suggests maintain the worry
process, while research has examined these phenomenon in
child and adolescent populations, there may be benefits to
more research in this area to resolve gaps in the theory. For
example, longitudinal designs may help determine the
direction of the relationship between behaviors and emotions that are associated with beliefs about worry, and
determine whether these factors have a cyclical relationship. Regarding the role of thought suppression in managing worry, future studies may replicate previous research
on this topic using clinical and non-clinical samples of
children and adolescents. This may help to identify whether
differences between studies regarding the role of thought
suppression are due to weaknesses of metacognitive theory,
or because of the use of different measures of this phenomenon across different studies.
The Measurement of Worry
It is important that ongoing research into worry and
metacognitive theory utilizes measures that have been
Clin Child Fam Psychol Rev (2010) 13:151–163
validated using child and adolescent populations, such as
the PSWQ-C. Many of the studies included in this review
used different measures of worry, including self-report
questionnaires and non-standardized interviews. Several of
these measures only had limited work done on their psychometric properties. This makes it difficult to compare
results across studies and evaluate the applicability of the
metacognitive model to children and adolescents.
As such, further research may benefit from evaluating
the psychometric properties of measures of child and
adolescent worry using large samples of clinical and nonclinical participants. In particular, to enable ongoing
research into metacognitive theory in child and adolescent
populations, future research may benefit from a further
evaluation of the psychometric properties of the MCQ-C
and the MCQ-A. This may include examining their internal
consistency and convergent and divergent validity, and
replicating the factors suggested by Bacow et al. (2009)
and Cartwright-Hatton et al. (2004) through the use of
confirmatory factor analysis. In doing so, it may be also be
important to consider developmental factors, in terms of
how the development of worry may influence the measurement of worry.
Metacognitive Therapy
Given the fundamental premise of metacognitive theory
that beliefs about worry are associated with worry and
other emotional symptoms, treatments for adults with GAD
have been developed that focus on modifying positive and
negative metacognitive beliefs about worry (Wells 2009).
Metacognitive therapy (MCT) suggests that rather than
challenging the content of worries, treatment may instead
address the underlying cognitive processes contributing to
the development and maintenance of pathological worry.
Specifically, treatment helps the client to identify and
modify negative metacognitive beliefs regarding the
uncontrollability and danger of worry (Wells 2009). Positive beliefs about worry are also modified, and more
helpful coping strategies for managing threat are developed, such as problem solving. For a review of the specific
strategies used in MCT; see Wells (2009). Preliminary
research has found that MCT provided to ten adult patients
with GAD was highly effective, with significant improvements in worry, anxiety, and depression post-treatment
(Wells and King 2006). These results have important
clinical implications, in terms of enhanced treatments for
adult worry. These results also provide further support for
the significance of metacognitive theory in understanding
worry in adult populations, by emphasizing the importance
of beliefs about worry in adults with GAD.
Preliminary research has supported the use of MCT
in treating adolescent anxiety. Simons, Schneider, and
161
Herpetz-Dahlmann (2006) conducted a preliminary study
that examined the effectiveness of MCT in a sample of 10
adolescents with OCD aged from 8 to 17. Participants
completed up to 20 weekly sessions of treatment, which
included some parent sessions. Metacognitive beliefs were
challenged, and metacognitive strategies were modified.
For example, rather than suppressing thoughts, participants
were encouraged to permit or accept them. Simons et al.
(2006) found that there were significant reductions in OCD
symptom severity following MCT, with these gains being
maintained for up to 2 years.
However, at the present time, it is too early to endorse
the development of MCT programs for the treatment of
worry in children and adolescents. We first need to better
understand the cognitive processes that contribute to the
development and maintenance of worry in young people. If
further research demonstrates that beliefs about worry are
significant in large populations of clinical and non-clinical
youth, this may establish the value of developing an
intervention that specifically targets metacognition.
Research that employs interventions that target metacognitive beliefs in child and adolescent populations may also
assist in testing key components of the metacognitive
model. If it were demonstrated that MCT is effective in
altering positive and negative beliefs about worry in this
population, and these modifications in beliefs were associated with reduced emotional symptoms, then further
support for metacognitive theory would be provided.
Results from this research may then inform the treatment of
worry and guide subsequent research in this area.
In summary, research that has been conducted thus far is
promising in terms of enhancing an understanding of
pathological worry in young people. However, several
areas have been identified that may benefit from future
research, particularly the assessment of worry, and the
applicability of the metacognitive model in child and
adolescent populations. It is only through ongoing research
that our understanding of worry can be further advanced in
child and adolescent populations.
References
Aaron, J., Zaglul, H., & Emery, R. E. (1999). Posttraumatic stress in
children following acute physical injury. Journal of Pediatric
Psychology, 24, 335–343.
American Psychiatric Association. (1994). Diagnostic and statistical
manual of mental disorders. Washington, DC: American Psychiatric Association.
Bacow, T. L., Pincus, D. B., Ehrenreich, J. T., & Brody, L. R. (2009).
The metacognitions questionnaire for children: Development and
validation in a clinical sample of children and adolescents with
anxiety disorders. Journal of Anxiety Disorders, 23, 727–736.
123
162
Baker, C. A., & Morrison, A. P. (1998). Cognitive processes in
auditory hallucinations: Attributional biases and metacognition.
Psychological Medicine, 28, 1199–1208.
Barahmand, U. (2008). Age and gender differences in adolescent
worry. Personality and Individual Differences, 45, 778–783.
Barlow, D. H. (2002). Anxiety and its disorders: The nature and
treatment of anxiety and panic. New York, NY: The Guildford
Press.
Bernstein, G. A. (1991). Comorbidity and severity of anxiety and
depressive disorders in a clinic sample. Journal of the American
Academy of Child & Adolescent Psychiatry, 30, 43–50.
Bernstein, G. A., & Layne, A. E. (2006). Separation anxiety disorder
and generalized anxiety disorder. In M. K. Dulcan & J. M.
Wiener (Eds.), Essentials of child and adolescent psychiatry
(pp. 415–439). Arlington, VA: American Psychiatric Publishing,
Inc.
Birmaher, B., Khetarpal, S., Brent, D., Cully, M., Balach, L.,
Kaufman, J., et al. (1997). The Screen for Child-Anxiety-Related
Emotional Disorders (SCARED): Scale construction and psychometric characteristics. Journal of the American Academy of
Child & Adolescent Psychiatry, 36, 545–553.
Borkovec, T., Robinson, E., Pruzinsky, T., & DePree, J. A. (1983).
Preliminary exploration of worry: Some characteristics and
processes. Behaviour Research and Therapy, 21, 9–16.
Boyle, M. H., Offord, D. R., Racine, Y., Sanford, M., Szatmari, P.,
Fleming, J. E., et al. (1993). Evaluation of the Diagnostic Interview
for Children and Adolescents for use in general population
samples. Journal of Abnormal Child Psychology, 21, 663–681.
Cartwright-Hatton, S., Mather, A., Illingworth, V., Brocki, J.,
Harrington, R., & Wells, A. (2004). Development and preliminary validation of the Meta-Cognitions Questionnaire-Adolescent version. Journal of Anxiety Disorders, 18, 411–422.
Cartwright-Hatton, S., & Wells, A. (1997). Beliefs about worry and
intrusions: The Meta-Cognitions Questionnaire and its correlates. Journal of Anxiety Disorders, 11, 279–296.
Chorpita, B. F., Tracey, S. A., Brown, T. A., Collica, T. J., & Barlow,
D. H. (1997). Assessment of worry in children and adolescents:
An adaptation of the Penn State Worry Questionnaire. Behaviour
Research and Therapy, 35, 569–581.
Craske, M. G. (1999). Anxiety disorders: Psychological approaches
to theory and treatment. Boulder, CO: Westview Press.
Davey, G. C. L., Hampton, J., Farrell, J., & Davidson, S. (1992).
Some characteristics of worrying: Evidence for worrying and
anxiety as separate constructs. Personality and Individual
Differences, 13, 133–147.
Davis, R. N., & Valentiner, D. P. (2000). Does meta-cognitive theory
enhance our understanding of pathological worry and anxiety?.
Personality and Individual Differences, 29, 513–526.
Ehlers, A., Mayou, R. A., & Bryant, R. (2003). Cognitive predictors of
posttraumatic stress disorder in children: Results of prospective
longitudinal study. Behaviour Research and Therapy, 41, 1–10.
Farrell, L., & Barrett, P. (2006). Obsessive-compulsive disorder
across developmental trajectory: Cognitive processing of threat
in children, adolescents and adults. British Journal of Psychology, 97, 95–114.
Flavell, J. H. (1999). Cognitive development: Children’s knowledge
about the mind. Annual Review of Psychology, 50, 21–45.
Flavell, J. H., Green, F. L., & Flavell, E. R. (1998). The mind has a
mind of its own: Developing knowledge about mental uncontrollability. Cognitive Development, 13, 127–138.
Flavell, J. H., Green, F. L., & Flavell, E. R. (2000). Development of
children’s awareness of their own thoughts. Journal of Cognition
and Development, 1, 97–112.
Flavell, J. H., Green, F. L., Flavell, E. R., Harris, P. L., & Astington,
J. W. (1995). Young children’s knowledge about thinking.
123
Clin Child Fam Psychol Rev (2010) 13:151–163
Monographs of the Society for Research in Child Development,
60, 1–113.
Ford, T., Goodman, R., & Meltzer, H. (2003). The British Child and
Adolescent Mental Health Survey 1999: The prevalence of
DSM-IV disorders. Journal of the American Academy of Child &
Adolescent Psychiatry, 42, 1203–1211.
Freeston, M. H., Rheaume, J., Letarte, J., Dugas, M. J., & Ladouceur,
R. (1994). Why do people worry. Personality and Individual
Differences, 17, 791–802.
Gosselin, P., Ladouceur, R., Langlois, F., Freeston, M. H., Dugas, M.,
& Bertrand, J. (2007a). Development and validation of a new
instrument to evaluate erroneous beliefs about worries. European Review of Applied Psychology, 53, 199–211.
Gosselin, P., Langlois, F., Freeston, M. H., Ladouceur, R., Dugas, M.
J., & Pelletier, O. (2002). The Cognitive Avoidance Questionnaire (CAQ): Development and validation among adult and
adolescent samples. Journal de The0 rapie Comportementale et
Cognitive, 12, 24–37.
Gosselin, P., Langlois, F., Freeston, M. H., Ladouceur, R., Laberge,
M., & Lemay, D. (2007b). Cognitive variables related to worry
among adolescents: Avoidance strategies and faulty beliefs about
worry. Behaviour Research and Therapy, 45, 225–233.
Henker, B., Whalen, C. K., & O’Neil, R. (1995). Worldly and
workaday worries: Contemporary concerns of children and
young adolescents. Journal of Abnormal Child Psychology, 23,
685–702.
Hudson, J. L., Hughes, A. A., & Kendall, P. C. (2004). Treatment of
generalized anxiety disorder in children and adolescents. In
P. M. Barrett & T. H. Ollendick (Eds.), Handbook of interventions that work with children and adolescents: Prevention and
treatment (pp. 115–143). New York, NY: Wiley.
Keller, M. B., Lavori, P. W., Wunder, J., Beardslee, W. R., Schwartz,
C. E., & Roth, J. (1992). Chronic course of anxiety disorders in
children and adolescents. Journal of the American Academy of
Child & Adolescent Psychiatry, 31, 595–599.
Kuhn, D. (1999). Metacognitive development. In L. Balter & C. S.
Tamis-LeMonda (Eds.), Child psychology: A handbook of
contemporary issues (pp. 259–286). New York, NY, US:
Psychology Press.
Kuhn, D. (2000a). Adolescence: Adolescent thought processes. In
A. E. Kazdin (Ed.), Encyclopedia of psychology (Vol. 1, pp. 52–
59). New York, NY: Oxford University Press.
Kuhn, D. (2000b). Metacognitive development. Current Directions in
Psychological Science, 9, 178–181.
Kuhn, D. (2000c). Theory of mind, metacognition, and reasoning:
A life-span perspective. In J. R. Mitchell & P. Riggs (Eds.),
Children’s reasoning and the mind (pp. 301–326). Hove,
England: Psychology Press/Taylor & Francis.
Last, C. G., Perrin, S., Hersen, M., & Kazdin, A. E. (1992). DSM-IIIR anxiety disorders in children: Sociodemographic and clinical
characteristics. Journal of the American Academy of Child &
Adolescent Psychiatry, 31, 1070–1076.
Laugesen, N., Dugas, M. J., & Bukowski, W. M. (2003). Understanding adolescent worry: The application of a cognitive model.
Journal of Abnormal Child Psychology, 31, 55–64.
March, J. S. (1997). Manual for the Multidimensional Anxiety Scale
for children. Toronto, Ontario: Multihealth Systems.
Masi, G., Mucci, M., Favilla, L., Romano, R., & Poli, P. (1999).
Symptomatology and comorbidity of generalized anxiety disorder in children and adolescents. Comprehensive Psychiatry, 40,
210–215.
Mather, A., & Cartwright-Hatton, S. (2004). Cognitive predictors of
obsessive-compulsive symptoms in adolescence: A preliminary
investigation. Journal of Clinical Child and Adolescent Psychology, 33, 743–749.
Clin Child Fam Psychol Rev (2010) 13:151–163
Matthews, L., Reynolds, S., & Derisley, J. (2007). Examining
cognitive models of obsessive compulsive disorder in adolescents. Behavioural and Cognitive Psychotherapy, 35, 149–163.
Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990).
Development and validation of the Penn State Worry Questionnaire. Behaviour Research Therapy, 28, 487–495.
Muris, P., Meesters, C., Merckelbach, H., Sermon, A., & Zwakhalen,
S. (1998). Worry in normal children. Journal of the American
Academy of Child & Adolescent Psychiatry, 37, 703–710.
Muris, P., Merckelbach, H., Gadet, B., & Moulaert, V. (2000). Fears,
worries, and scary dreams in 4- to 12-year-old children: Their
content, developmental pattern, and origins. Journal of Clinical
Child Psychology, 29, 43–52.
Muris, P., Merckelbach, H., & Luijten, M. (2002a). The connection
between cognitive development and specific fears and worries in
normal children and children with below-average intellectual
abilities: A preliminary study. Behaviour Research and Therapy,
40, 37–56.
Muris, P., Merckelbach, H., Meesters, C., & van den Brand, K.
(2002b). Cognitive development and worry in normal children.
Cognitive Therapy and Research, 26, 775–785.
Papageorgiou, C. (2006). Worry and rumination: Styles of persistent
negative thinking in anxiety and depression. In G. C. L. Davey &
A. Wells (Eds.), Worry and its psychological disorders: Theory,
assessment and treatment (pp. 21–40). Hoboken, NJ: Wiley
Publishing.
Papageorgiou, C., & Wells, A. (1998). Effects of attention training on
hypochondriasis: A brief case series. Psychological Medicine,
28, 193–200.
Papageorgiou, C., & Wells, A. (2001). Metacognitive beliefs about
rumination in recurrent major depression. Cognitive and Behavioral Practice, 8, 160–164.
Perrin, S., & Last, C. G. (1997). Worrisome thoughts in children
clinically referred for anxiety disorder. Journal of Clinical Child
Psychology, 26, 181–189.
Piaget, J. (1970). Piaget’s theory. In P. H. Mussen (Ed.), Carmichaels’s manual of child psychology (Vol. I, pp. 703–732).
New York: Wiley.
Pine, D. S., Cohen, P., Gurley, D., Brook, J., & Ma, Y. (1998). The
risk for early-adulthood anxiety and depressive disorders in
adolescents with anxiety and depressive disorders. Archives of
General Psychiatry, 55, 56–64.
Reynolds, C. R., & Richmond, B. O. (1978). What I think and feel:
A revised measure of children’s manifest anxiety. Journal of
Abnormal Child Psychology, 6, 271–280.
Schniering, C. A., Hudson, J. L., & Rapee, R. M. (2000). Issues in the
diagnosis and assessment of anxiety disorders in children and
adolescents. Clinical Psychology Review, 20, 453–478.
Silverman, W. K., La Greca, A. M., & Wasserstein, S. (1995). What
do children worry about? Worries and their relation to anxiety.
Child Development, 66, 671–686.
Simons, M., Schnieder, S., & Herpetz-Dahlmann, B. (2006). Metacognitive therapy versus exposure and response prevention for
pediatric obsessive-compulsive disorder. Psychotherapy and
Psychosomatics, 75, 257–264.
Spence, S. H. (1997). Structure of anxiety symptoms among children:
A confirmatory factor-analytic study. Journal of Abnormal
Psychology, 106, 280–297.
163
Spruijt-Metz, D., & Spruijt, R. J. (1997). Worries and health in
adolescence: A latent variable approach. Journal of Youth and
Adolescence, 26, 485–501.
Strauss, C. C., Lease, C. A., Last, C. G., & Francis, G. (1988).
Overanxious disorder: An examination of developmental differences. Journal of Abnormal Child Psychology, 16, 433–443.
Tallis, F., Eysenck, M. W., & Matthews, A. (1992). Worry: A critical
analysis of some theoretical approaches. Anxiety Research, 4,
97–108.
Vasey, M. W. (1993). Development and cognition in childhood
anxiety: The example of worry. Advances in Clinical Child
Psychology, 15, 1–39.
Vasey, M. W., Crnic, K. A., & Carter, W. G. (1994). Worry in
childhood: A developmental perspective. Cognitive Therapy and
Research, 18, 529–549.
Vasey, M. W., & Daleiden, E. L. (1994). Worry in children. In G. C.
L. Davey & F. Tallis (Eds.), Worrying: Perspectives on theory,
assessment and treatment (pp. 185–207). Oxford, England:
Wiley.
Weems, C. F., Silverman, W. K., & La Greca, A. M. (2000). What do
youth referred for anxiety problems worry about? Worry and its
relation to anxiety and anxiety disorders in children and
adolescents. Journal of Abnormal Child Psychology, 28, 63–72.
Wegner, D. M., & Zanakos, S. (1994). Chronic thought suppression.
Journal of Personality and Social, 62, 615–640.
Wells, A. (1995). Meta-cognition and worry: A cognitive model of
generalized anxiety disorder. Behavioural and Cognitive Psychotherapy, 23, 301–320.
Wells, A. (2004). A cognitive model of GAD: Metacognitions and
pathological worry. In R. G. Heimberg, C. L. Turk, & D. S.
Mennin (Eds.), Generalized anxiety disorder: Advances in
research and practice (pp. 164–186). New York: The Guildford
Press.
Wells, A. (2007). Cognition about cognition: Metacognitive therapy
and change in generalized anxiety disorder and social phobia.
Cognitive and Behavioral Practice, 14, 18–25.
Wells, A. (2009). Metacognitive therapy for anxiety and depression.
New York, NY: The Guildford Press.
Wells, A., & Carter, K. (1999). Preliminary tests of a cognitive model
of generalized anxiety disorder. Behaviour Research and Therapy, 37, 585–594.
Wells, A., & Carter, K. (2001). Further tests of a cognitive model of
generalized anxiety disorder: Metacognitions and worry in GAD,
panic disorder, social phobia, depression, and nonpatients.
Behavior Therapy, 32, 85–102.
Wells, A., & Cartwright-Hatton, S. (2004). A short form of the
metacognitions questionnaire: Properties of the MCQ-30.
Behaviour Research and Therapy, 42, 385–396.
Wells, A., & King, P. (2006). Metacognitive therapy for generalized
anxiety disorder: An open trial. Journal of Behavior Therapy and
Experimental Psychiatry, 37, 206–212.
Wells, A., & Papageorgiou, C. (1995). Worry and the incubation of
intrusive images following stress. Behaviour Research and
Therapy, 33, 579–583.
Wells, A., & Papageorgiou, C. (1998). Relationships between worry,
obsessive-compulsive symptoms and meta-cognitive beliefs.
Behaviour Research and Therapy, 36, 899–913.
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