The metacognitions questionnaire for children: Development and validation in a clinical sample of children and adolescents with anxiety disorders

Journal of Anxiety Disorders 23 (2009) 727–736

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Journal of Anxiety Disorders

The metacognitions questionnaire for children: Development and validation in a clinical sample of children and adolescents with anxiety disorders Terri Landon Bacow 3,*, Donna B. Pincus, Jill T. Ehrenreich 2, Leslie R. Brody 1 Boston University, Center for Anxiety and Related Disorders, 648 Beacon Street, 6th Floor, Boston, MA 02215, United States

A R T I C L E I N F O

A B S T R A C T

Article history: Received 2 October 2008 Received in revised form 25 February 2009 Accepted 26 February 2009

A self-report measure of metacognition for both children and adolescents (ages 7–17) (Metacognitions Questionnaire for Children; MCQ-C) was adapted from a previous measure, the MCQ-A (Metacognitions Questionnaire for Adolescents) and was administered to a sample of 78 children and adolescents with clinical anxiety disorders and 20 non-clinical youth. The metacognitive processes included were (1) positive beliefs about worry (positive meta-worry); (2) negative beliefs about worry (negative metaworry); (3) superstitious, punishment and responsibility beliefs (SPR beliefs) and (4) cognitive monitoring (awareness of one’s own thoughts). The MCQ-C demonstrated good internal-consistency reliability, as well as concurrent and criterion validity, and four valid factors. In line with predictions, negative meta-worry was significantly associated with self-reports of internalizing symptoms (excessive worry and depression). Age-based differences on the MCQ-C were found for only one subscale, with adolescents reporting greater awareness of their thoughts than children. Adolescent girls scored higher on the total index of metacognitive processes than adolescent boys. Overall, these results provide preliminary support for the use of the MCQ-C with a broader age range as well as an association between metacognitive processes and anxiety symptomatology in both children and adolescents, with implications for cognitive behavioral interventions with anxious youth. ß 2009 Elsevier Ltd. All rights reserved.

Keywords: Metacognition Childhood Adolescence Anxiety Diagnosis

1. Introduction Selective attention to internal events is thought to be a key factor in the development of anxiety and other emotional difficulties (Wells & Matthews, 1994). The importance of cognition (i.e., disordered thinking) in the emotional functioning of adults has been widely established (Clark, 2001) and preliminary studies are beginning to suggest that the same is true for younger populations. For example, anxious youth often present to the clinical setting with repetitive or bothersome thoughts about anticipated negative outcomes or feared events (Comer, Kendall, Franklin, Hudson, & Pimental, 2004). Yet, few empirical studies have examined cognitive factors specifically in development and maintenance of worry in children and adolescents (Laugesen, Dugas, & Bukowski, 2003) and relatively little is known about children’s interpretations or appraisals of their own worry processes, which fall under the category of metacognitive processes.

* Corresponding author. Tel.: +1 917 710 0846. E-mail address: [email protected] (T.L. Bacow). 1 Department of Psychology, Boston University. 2 Now at the Department of Psychology, University of Miami. 3 Now at the Mount Sinai School of Medicine in New York, NY. 0887-6185/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.janxdis.2009.02.013

The construct of metacognition, commonly viewed as thinking about thinking, was first introduced by Flavell (1979). According to the framework outlined by Brown and colleagues, metacognition broadly involves: (1) introspective knowledge about one’s cognitive states and abilities and their operation, along with (2) the ability to use metacognitive knowledge strategically to achieve goals (strategy regulation) and (3) cognitive monitoring of thoughts (the ability to read one’s own mental state) (Brown, Bransford, Ferrera, & Campione, 1983; Pressley, Borkowki, & O’Sullivan, 1985; Wellman, 1985). More succinctly, metacognition includes any knowledge or cognitive process that is involved in the appraisal, monitoring or control of cognition (Flavell, 1979; Moses & Baird, 1998). In the adult literature, Wells (2000) has posited that the beliefs that individuals have about their thoughts and thought processes, which he categorizes as metacognitive knowledge, are linked to their emotional well-being. As certain aspects of disturbances in thinking characteristic of emotional disorders are located at the belief level, it is important to consider the influence of metacognitive knowledge on anxiety and depression. For example, it has been found that while people generally believe that worrying can be advantageous, adults with generalized anxiety disorder (GAD) tend to believe that worrying is uncontrollable and dangerous (Cartwright-Hatton & Wells, 1997; Wells, 1995); furthermore, these beliefs about worry (worry about worry itself)

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have been found to contribute to development and maintenance of the disorder. Over the past several years, Wells and colleagues have conducted a number of studies with clinical and non-clinical adult populations examining a number of specific metacognitive beliefs in a range of anxiety disorders, particularly in GAD and OCD (e.g., Wells & Carter, 1999, 2001). Wells and colleagues have described a metacognitive model outlining the role of these beliefs in the emergence and maintenance of anxiety disorders in adults, as well as a Metacognitions Questionnaire (MCQ) to assess these types of beliefs (Wells & Carter, 1999). Are metacognitive beliefs and related processes important to consider for children and adolescents with anxiety disorders as well? The growing interest in metacognition and worry in the adult literature has just recently begun to appear in the adolescent literature, examining whether younger individuals hold similar metacognitive beliefs about their thought processes. CartwrightHatton, Mather, Illingworth, Harrington, and Wells (2004) developed an adolescent version of the MCQ (MCQ-A) and administered it to youth between the ages of 13 and 17. The MCQ-A, like the MCQ, has five subscales: (1) positive meta-worry (positive beliefs about worry, such as, ‘‘Worrying helps me solve problems’’); (2) negative meta-worry (negative beliefs about worry, such as, ‘‘Worrying might make me go crazy’’); (3) superstitious, punishment and responsibility beliefs linking thoughts to negative outcomes (SPR beliefs); (4) cognitive self-consciousness (awareness of one’s own thoughts) and (5) cognitive confidence (confidence in one’s memory and attentional abilities) (Cartwright-Hatton et al., 2004). When administering the MCQ-A to a large sample of adolescents, Cartwright-Hatton et al. (2004) found that they endorsed a range of metacognitive beliefs on the MCQ-A, identical to those identified in adult populations. Moreover, the small clinical sample of adolescents in their study (adolescents with diagnoses of emotional disorders; n = 11) endorsed a greater number of items than non-clinical participants (non-clinical, school-aged children; n = 166) across three of the subscales (negative meta-worry, SPR beliefs and cognitive self-confidence), consistent with findings with adults. In contrast, the clinical and non-clinical groups did not score differently from each other on the positive meta-worry or the cognitive self-consciousness subscales of the measure. In a follow-up study focusing on OCD, Mather and Cartwright-Hatton (2004) found that the total score of the MCQ-A was associated with obsessive-compulsive symptoms (measured by the Leyton Obsessional Inventory-Child Version Survey Form; Berg, Whitaker, Davies, Flament, & Rapoport, 1988) in non-clinical adolescents and remained an independent predictor of obsessivecompulsive symptoms after controlling for age, sex and depression. Matthews, Reynolds, and Derisley (2006) then explored the relationship between metacognitive beliefs (measured by the MCQ-A) and obsessional symptoms in a group of non-clinical adolescents (ages 13–16). They found that metacognitive beliefs in general were strongly associated with higher levels of obsessivecompulsive symptoms and that when compared to thought-action fusion, metacognitive beliefs and inflated responsibility both emerged as significant independent predictors of OCD symptoms. Although they did not report findings from specific metacognitive subscales, the authors conclude that, ‘‘Cognitive models of Obsessive-Compulsive Disorder appear to be as applicable to young people as they are to adults, and the measures used to assess cognition are appropriate to this age group’’ (Matthews et al., 2006, p. 159). Further support for the applicability of metacognitive belief measures to youth was found in the Cartwright-Hatton et al. (2004) study. When they examined developmental patterns in their adolescent sample in the paper piloting this measure, the degree to which MCQ-A beliefs were endorsed did not appear to

increase with age; in fact, the youngest adolescents (13-yearolds) reported the highest metacognitive scores. According to the authors, this raises the possibility that these concepts are near fully developed by the age of 13. Cartwright-Hatton et al. (2004) indicate that if this is the case, it would be useful to see whether even younger children might report metacognitive beliefs. To date, no studies have investigated whether specific metacognitive processes (metacognitive appraisals of thoughts and awareness of thoughts) are linked to anxiety and other affective disorders in children younger than 13 years of age, or examined this potential relationship in a large clinical sample of anxiety-disordered youth. However, a study investigating children’s knowledge and beliefs about their own worry indicated that up to 30% of the participants (non-clinical youth who were between the ages of 8 and 13) expressed an opinion about the origin(s) of their worry (Muris, Meesters, Merckelbach, Sermon, & Zwakhalen, 1998). In the same study, 28% of children reported positive features of their worry, although notably, none of the children who scored in the putative clinical range were able to do so. The need for further exploration of metacognitive processes in younger individuals suggests that it would be beneficial to have a Metacognitions Questionnaire for Children (MCQ-C) that can be utilized across the full child–adolescent age spectrum, thus examining any age-based differences in these metacognitive processes. Such a measure could also explore outcomes with both a clinical and non-clinical population of youth. In particular, a child and adolescent specific MCQ-C would be potentially useful in answering a number of important questions about the metacognitive factors involved in childhood anxiety disorders. Of note, previous studies with adults that have explored metacognitive processes (utilizing the MCQ) with individuals with anxiety disorders have examined associations between these processes and emotional symptoms independently of a third factor, the content and excessiveness of worry (which they refer to as ‘‘Type I Worry’’). For example, Wells and Carter (2001) found that the ability of different metacognitive processes to distinguish amongst anxiety disorder diagnostic groups (i.e., generalized anxiety disorder, panic disorder and social phobia) was improved when the excessive content of individuals’ worry was controlled for. This points to the distinction between the topics that people worry about excessively (e.g., worrying about one’s own performance at work; worrying about one’s partner’s health, worrying about current events) and metacognitive worry (e.g., worry about worry itself). Wells and Carter (1999, 2001) argue that although both types of worry should be significantly related to clinical worry disorders, metacognitive worry in particular should predict pathological worry independently of excessive worry content. This hypothesis was supported in several studies in which these constructs were examined (e.g., Davis & Valentiner, 2000; Wells, 2005; Wells & Carter, 1999, 2001; Wells & Papageorgiou, 1998). Given these findings and to be consistent with previous research, it would be helpful to utilize a youth-specific self-report measure of metacognition to determine whether there are associations between metacognitive processes and anxiety disorders in children and adolescents when the potentially excessive content of their worries is held constant. Finally, the relationship between metacognitive processes and gender in children is lacking and needs additional exploration. Although Cartwright-Hatton et al. (2004) and Matthews et al. (2006) found that adolescent girls did not differ from boys in their reports on the MCQ-A, studies examining anxiety in younger populations tend to find that girls display higher symptom levels of anxiety and depression, as well as higher levels of rumination, worry and a negative attributional style than boys (Bernstein, Borchardt, & Perwein, 1996; Muris, Roelofs, Meesters, & Boomsma,

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2004). Therefore, it is certainly possible that girls may be more likely to engage in the metacognitive processes characteristic of anxiety disorders than boys, particularly in a group of youth with anxiety as their primary problem. The main goal of this study was to report the development of a Metacognitions Questionnaire for Children (MCQ-C) that can be utilized across the full child–adolescent age spectrum, thus examining any age-based differences in these metacognitive processes as well as outcomes with both a clinical and non-clinical population of youth. We predicted that confirmatory factor analyses would yield a factor structure similar to that of the Meta-cognitions Questionnaire for Adolescents (Cartwright-Hatton et al., 2004) and that each subscale and the entire scale would evidence satisfactory internal consistency. To establish concurrent validity, we proposed that participants’ scores on the MCQ-C would be significantly and positively associated with measures of internalizing symptoms (excessive worry and depression). Moreover, consistent with Wells and Carter’s (2001) work, the relationship between MCQ-C metacognition subscale scores and the excessive content of children’s worries was investigated and we predicted that these relationships would remain significant when excessive worry content was controlled. With regard to criterion validity, it was hypothesized that youth with a diagnosis of an anxiety disorder would score significantly more highly on the instrument than matched non-clinical participants and that this difference would remain significant when excessive worry content was held constant. In addition, this study has two additional ancillary goals: to examine the association between select metacognitive processes and: (1) chronological age and (2) gender. Four metacognitive processes were selected for examination in this investigation: positive and negative meta-worry, superstitious, punishment and responsibility beliefs, and cognitive monitoring (awareness of thoughts, labeled ‘‘cognitive self-consciousness’’ in the MCQ-A). 2. Method 2.1. Participants A total of 98 children between the ages of 7 and 17 years participated in the study. Seventy-eight children were in the clinical sample and 20 children were in the non-clinical sample. A lower age limit of 7 years was selected because in order to participate, children needed to be able to describe their thoughts and anticipate their actions well enough to respond accurately to the measures being administered (Vasey, Crnic, & Carter, 1994). In addition, there is evidence to suggest that children may be capable of engaging in an adult-like worry process as young as 7 or 8 years of age (Vasey & Daleiden, 1994), and that this ability to worry is linked to the developing metacognitive knowledge that children in this age range possess (Flavell, Green, & Flavell, 1995; Muris, Merckelbach, Meesters, & van den Brand, 2002). In fact, metacognitive knowledge about strategies and tasks is thought to appear after children enter school, and may be related to the onset of the concrete operational stage which emerges in children at age 7 (Piaget, 1970). The upper age limit of 17 was selected so that adolescents could be included in the study, and to provide a broad enough age range to examine age-related differences in responses to the measures. This upper age limit is also consistent with previous research examining the types of variables utilized in this study (Cartwright-Hatton et al., 2004). The clinical sample (n = 78, 29 boys, 49 girls, mean age = 11.86, SD = 3.11) was comprised of children and adolescents who were recruited via consecutive clinical referrals to a University-based research clinic and met DSM-IV-TR (American Psychiatric Association, 2000) criteria for a principal anxiety disorder diagnosis of (1)

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generalized anxiety disorder (GAD) (n = 20); (2) obsessive compulsive disorder (OCD) (n = 18); (3) social anxiety disorder (SOC) (n = 20); or (4) separation anxiety disorder (SAD) (n = 20). Clinical participants were predominantly Caucasian (98%). Diagnoses were made using the Anxiety Disorders Interview Schedule, Child and Parent Versions (ADIS-IV-C/P; Silverman & Albano, 1996). These children were included even if they met criteria for additional, comorbid diagnoses (anxiety, depressive or behavioral disorders) that were less severe and/or interfering due to the difficulty of recruiting children with single anxiety disorder diagnoses. Research has found that comorbidity among children with anxiety disorders is extremely common (Brady & Kendall, 1992; Lewinsohn, Zinbarg, Seeley, Lewinsohn, & Sack, 1997). In the present study, 60% of the children had at least one additional anxiety disorder, 12% met criteria for an additional depressive disorder, and 13% met criteria for an additional behavioral, attentional, impulse control disorder or learning disability. Children with comorbid pervasive developmental disorder, mental retardation, bipolar disorder, and psychosis, however, were excluded from the present study, as these were general exclusion criteria for the larger research clinic. Twenty additional children and adolescents from the community (7 boys, 13 girls), ages 7–17 (mean age = 12.41, SD = 3.02) served as participants. Of the non-clinical participants, 17 were Caucasian (85%), 2 were African-American (10%), and 1 was Latino (5%). The non-clinical children and adolescents were primarily recruited from advertisements posted on an Internet bulletin board and from fliers posted in the community. Inclusion criteria for non-clinical participants included (a) no diagnosis of a mental disorder according to an abbreviated version of the parent-report version of the ADIS-IV-C/P (Silverman & Albano, 1996) or (b) one or more subclinical diagnosis of a mental disorder (with a Clinician Severity Rating [CSR] below four). Specifically, 8 (40%) of the non-clinical participants had no mental disorder, while 12 (60%) had subclinical symptoms of one or more mental disorder(s). Demographic characteristics of both the clinical and non-clinical samples, including participants’ age, gender, ethnicity, household income, parents’ marital status and parents’ education were examined. For the clinical sample, household income information was available for only 50 participants (64%). There were no statistically significant differences between the groups on age, gender, reported household income or parents’ education level. Notably, there was a significant difference in ethnicity between the groups x2 = 16.24, p < 0.01 suggesting that there was a broader representation of different ethnicities amongst the non-clinical sample. With regard to family characteristics, the parents of both groups were primarily Caucasian, affluent and college educated. 2.2. Procedure Clinical participants who met criteria to participate in the study were approached after receiving feedback about the results of their diagnostic assessment at the clinic. Those who agreed to participate completed the measures. For children and adolescents in the non-clinical sample who responded to internet and community advertisements, the study session was scheduled either at the clinic or at the participants’ home, with nine parents (45%) choosing to do the study at home. After the receipt of informed consent/assent, the participant’s mother was administered an abbreviated version of the ADIS-P. None of the children recruited to the non-clinical group met criteria for an anxiety or mood disorder at a clinical level. After these conditions were ruled out, the child or adolescent was asked to complete the same measures (the order of the self-report measures was

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counterbalanced). These measures were read aloud to children who needed reading assistance (only one child required assistance). 2.3. Measures 2.3.1. Anxiety disorders interview schedule, child and parent versions (ADIS-IV-C/P) The ADIS-IV C/P is a semi-structured clinical interview for the diagnosis of childhood anxiety and related disorders. Children and their parents are interviewed separately by a single interviewer, and the diagnoses are based on composite information from both interviews. A clinician severity rating (CSR) is assigned to each anxiety disorder diagnosis; CSR’s range from zero (Absent) to eight (Very Severe), with a CSR of four or higher representing a clinical diagnosis. Research demonstrates that the ADIS-IV-C/P has good interrater and test–retest reliability (Silverman & Eisen, 1992; Silverman & Nelles, 1988). Rapee, Barrett, and Dadds (1994) and Silverman, Saavedra, and Pina (2001) report kappa coefficients for specific anxiety disorder diagnoses. With regard to the university-based population utilized in this study, preliminary reliability analyses from 49 subjects revealed 90% interrater agreement of diagnostic severity (i.e., CSR) and 83% interrater agreement of diagnostic impression (i.e., what was assigned as principal diagnosis). In addition, support for convergent validity of the ADIS-IV-C/P has been found (Wood, Piancentini, Bergman, McCracken, & Barrios, 2002) in a study reporting high correlations between symptom ratings for the social phobia, separation anxiety, and panic disorder sections of the ADIS-IV/C-P and corresponding scales of the Multidimensional Anxiety Scale for Children (MASC; March, Parker James, & Sullivan, 1997). An abbreviated version containing select subsections of the ADIS-IVP was administered to parents of community participants. This version was selected to allow for screening of anxiety symptomatology (along with psychosis, bipolar disorder and developmental disorders. Furthermore, administration is not as timeconsuming as the ADIS-IV-C/P and thus represented less of a burden on community participants’ parents. DiBartolo, Albano, and Barlow (1998) suggest that for most children under 12 years of age, the parent’s report of the child’s symptomatology is more heavily weighed by clinicians in their estimation of consensus diagnosis. 2.3.2. Metacognitions questionnaire for children – child version (MCQ-C) To measure children and adolescents’ levels of cognitive monitoring, positive meta-worry, negative meta-worry and SPR beliefs, subscales of the Metacognitions Questionnaire for Children (MCQ-C) were administered (see Appendix A). The MCQ-C was developed for this study and is an adaptation of the Metacognitions Questionnaire for Adolescents (MCQ-A; Cartwright-Hatton et al., 2004). Briefly, the MCQ-A is a 30-item scale designed for adolescents between the ages of 13 and 17. It is a multicomponent measure of a range of metacognitive beliefs and monitoring tendencies in adolescents, specifically with relation to intrusive thinking, worry, cognitive functioning, and the tendency to monitor thought processes. The MCQ-A is comprised of five subscales, including Positive Beliefs About Worry (e.g., ‘‘Worrying helps me to avoid problems in the future’’); Cognitive Confidence (e.g., ‘‘I have a poor memory’’); Superstition, Punishment and Responsibility (e.g., ‘‘I will be punished for not controlling certain thoughts’’); Cognitive Self-Consciousness (e.g., ‘‘I pay close attention to the way my mind works’’); and Uncontrollability and Danger (e.g., ‘‘I could make myself sick with worrying’’). Participants are asked to indicate how much they agree with each statement on a four-point scale, labeled, ‘‘do not agree’’ at one extreme, and ‘‘agree very

much’’ at the other. The full MCQ-A scale has a test–retest reliability coefficient of 0.41, acceptable construct and discriminant validity (Cartwright-Hatton et al., 2004). For example, each MCQ-A subscale and its total score are significantly and positively correlated with measures of anxiety, depression, and obsessional symptoms (Cartwright-Hatton et al., 2004; Mather & Cartwright-Hatton, 2004). The MCQ-C differs from the MCQ-A in that it is intended to be applicable for a broader age range (children as well as adolescents). In the process of revision, attempts were made to consider issues involved in adapting a new measure from a previous version (Silverstein & Nelson, 2000). For example, to attend to content validity, item revision was based on presenting MCQ-A items to a pilot sample comprised of a younger sample of participants (see below) and eliciting feedback from these individuals as well as clinic staff (therapists familiar with child anxiety disorders and developmental issues). Another important aspect of content validity involves clearly defining the constructs intended to be measured (Haynes, Richard, & Kubany, 1995) and ensuring that the items are relevant (i.e., that they reflect the construct(s) being measured). Although metacognition is a broad concept, the MCQ-C is intended to capture the same, specific aspects of this construct that are represented in the subscales of the MCQ-A (meta-worry, thought monitoring and beliefs about the significance of thoughts). These aspects of metacognition are intended to be specific to emotional disorders and anxiety in particular (Wells, 2000). The measure was modified in a few ways for use in this study to be more understandable to children as young as age seven as well as adolescents. To assist in the development of revised and simplified language for use with younger children, the MCQ-A was administered in its original format to a pilot sample of children (N = 9) ages 7–14 (6 girls, 3 boys). Feedback was requested from these respondents regarding items, phrases and concepts that they did not understand and suggestions for improvement. This feedback was utilized to develop the revised MCQ for children, the MCQ-C. Clinic staff also provided feedback with regard to final decisions related to wording. Firstly, we removed any words or concepts that might be too advanced for the youngest age range. For example, ‘‘I monitor my thoughts’’ was changed to ‘‘I try hard to keep track of the thoughts I have in my head,’’ and ‘‘Worrying helps me cope’’ was modified to ‘‘Worrying helps me feel better.’’ Secondly, we attempted to make statements that had an ambiguous nature more specific, so that there would be less need for interpretation. As an example, the item, ‘‘My worrying is bad for me’’ was modified to, ‘‘It is not a good idea to worry because worrying is bad for me.’’ In addition, we reduced the frequency of multiple-syllable items and aimed to use phrases that were simpler. For example, ‘‘I constantly study my thoughts’’ became ‘‘I think a lot about my thoughts.’’ Finally, we removed terms and spelling that are not typically used by American youth (‘‘I need to worry in order to be organised’’ was altered to ‘‘Worrying about things helps me to be organized and keep my stuff in order.’’) The adapted measure has a Flesch-Kincaid reading grade level of 2.0. The MCQ-C also differs from the MCQ-A in that it is comprised of only four out of five of the original subscales, to reflect the four primary metacognitive variables of interest in this investigation. Although the fifth scale, cognitive confidence, has been associated with self-report measures of anxiety symptoms and GAD diagnostic status (Cartwright-Hatton et al., 2004; Davis & Valentiner, 2000; Ruscio & Borkovec, 2003; Wells & Papageorgiou, 1998), it was omitted in the present study for theoretical reasons. There is evidence suggesting that the cognitive confidence scale of the adult MCQ can best be represented by three separate factors: general confidence in memory, reality monitoring confidence, and confidence in keeping attentional focus, and that mistrust in attention may be more salient than mistrust in memory, particularly

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in the case of OCD (Hermans et al., 2008). Thus, we wished to omit this factor until future research could clarify this issue. Although the four subscales retained are functionally equivalent to the four constructs of interest in the present study, their names were modified slightly. Specifically, the Cognitive Self-Consciousness subscale is referred to as Cognitive Monitoring, the Positive Beliefs about Worry subscale represents positive meta-worry, and the Uncontrollability and Danger subscale is referred to as negative meta-worry. The name of the SPR subscale was retained, as it is a good descriptor of the construct of interest (negative beliefs about thoughts in general, with themes of superstition, punishment and responsibility). There are eight items on each subscale, and the sum of the items on the cognitive monitoring, negative meta-worry, positive meta-worry and SPR subscales were used in the analyses as measures of these constructs. The total score on the MCQ-C was also used in the analyses as a general measure of metacognitive awareness and processes. Internal consistency of the adapted MCQ-C is reported in Section 3. 2.3.3. Penn-state worry questionnaire for children (PSWQ-C; Chorpita, Tracey, Brown, Collica, & Barlow, 1997) The PSWQ-C is a 14-item, content-free measure of worry proneness, designed to assess the tendency of children to engage in excessive, generalized and uncontrollable worry. It was adapted from a 16-item adult version (Penn State Worry Questionnaire; Meyer, Miller, Metzeger, & Borkovec, 1990). Items are rated on a 4-point Likert-type scale ranging from 0 (not at all true) to 3 (always true). Total scores reported for school-based samples were 16.12 for 6–11-year-olds and 19.24 for 12–18-yearolds. The corresponding scores for children with anxiety disorders were between 21 and 27, and children diagnosed with GAD consistently scored higher than others (Chorpita et al., 1997). The PSWQ-C was found to be unifactorial and possess favorable reliability in terms of internal consistency (a = 0.88). Internal consistencies of 0.81 were reported for 6–11-year-old children and 0.90 for 12–18-year-olds. Good discriminant and convergent validity was also found, and a 1-week test–retest reliability coefficient of 0.92 was reported in a clinical sample (Chorpita et al., 1997). 2.3.4. Children’s depression inventory (CDI; Kovacs, 1981) The CDI is a widely used self-report measure of depressive symptoms in children and adolescents 7–17 years of age. The scale consists of 27 items designed to assess a variety of symptoms of depression, such as sleep disturbance, appetite loss, suicidal thoughts, and general dysphoria. CDI items have to be scored on three-point scales with 0 = not true, 1 = somewhat true, or 2 = very true. A total CDI score can be calculated by summing all item scores. The CDI is reported to demonstrate good internal consistency as well as discriminant validity from measures of anxiety (Romano & Nelson, 1988; Saylor, Finch, Spirito, & Bennett, 1984). Furthermore, the CDI has been evaluated with children between the ages of 4 and 18, demonstrating high internal consistency (Helsel & Matson, 1984; Romano & Nelson, 1988). 2.3.5. Measure of excessive worry content The GAD section of the ADIS-IV-C and Mini ADIS-IV-P was utilized to assess for excessive worry content (the overwhelming attention paid to worries of different content areas) (Referred to as ‘‘Type 1 Worry’’ by Wells & Carter, 2001). The GAD subscale assesses for eight domains of worry: (1) School, (2) Performance, (3) Social and Interpersonal Matters, (4) Perfectionism, (5) Health (Self), (6) Health (Others), (7) Family Matters and (8) Current Events. Children are asked to rate how much they worry about each topic on a scale from 0 to 8. The total score of all worry domain

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ratings in this section (Maximum Score = 64) comprised the estimate of excessive worry content. For example, if a child reported worrying about all eight topics and gave a rating of 8 for each, she received a score of 64. 3. Results 3.1. Preliminary analyses Zero-order correlations revealed significant and positive associations between excessive worry content and the total score of the MCQ-C and its subscales. A univariate regression analysis revealed that excessive worry content contributed to 27% of the variance in the total score of the MCQ-C (b = 0.38) and the relationship between worry content and the total MCQ-C score was significant. Thus, excessive worry content was selected as a control variable in subsequent analyses. Associations between the demographic variables and diagnostic status were also explored to assess for covariates. Chi-square analyses revealed that there were no observed gender differences or ethnicity differences (with ethnicity categorized as Caucasian, African-American, Asian and Latino or Hispanic) amongst youth with GAD, OCD, SOC or SAD. As mentioned previously, there was a significant difference in ethnicity between the clinical and non-clinical groups x2 = 16.24, p < 0.01 indicating a broader representation of different ethnicities amongst the nonclinical sample. However, since both groups were primarily Caucasian and research shows that rates of anxiety disorders do not seem to vary widely across ethnicities (Albano, Chorpita, & Barlow, 2003; Last, Perrin, Hersen, & Kadzin, 1992) we decided not to include this as a covariate. With regard to age differences, results of a one-way ANOVA comparing ages of participants with each diagnosis showed that the overall Welch F was significant (F, 3, 36.47) = 28.8, MSE = 4.44, p < 0.001. Post hoc comparisons using the GamesHowell procedure revealed that clinical participants with SAD (M = 8.59, SD = 1.36) were significantly younger than those with GAD (M = 11.37, SD = 1.77), OCD (M = 13.70, SD = 2.66) and SOC (M = 14.28, SD = 2.46). Furthermore, post hoc comparisons revealed that clinical participants with SOC (M = 14.28, SD = 2.46) and with OCD (M = 13.70, SD = 2.66) were significantly older than youth with GAD (M = 11.37, SD = 1.77) and SAD (M = 8.59, SD = 1.36). These results were not, however, unexpected given age-based prevalence rates finding that SAD is more common in younger children and that OCD and SOC tend to have their onset in early adolescence (Francis, Last, & Strauss, 1987; Last et al., 1992). 3.2. Factor analysis Confirmatory factor analyses were utilized to test the factor structure of the MCQ-C data. This methodology allows for the modeling of a predetermined structure of the data and to evaluate the goodness-of-fit of this hypothesized structure to the structure of competing models. Of note, our analysis was slightly underpowered (n = 98) and results should be interpreted with some caution (Thompson, 2004). We hypothesized a similar structure to the MCQ-C, with four factors instead of five. To test the goodnessof-fit and compare competing models, chi-square tests, Comparative Fit Index (CFI; >.95 is good fit), Akaike Information Criterion (AIC; lower is a better fit), Bayesian Information Criterion (BIC; lower is a better fit) and RMSEA were calculated. Modification Indices were also used to guide refinement of the hypothesized model including examining the possibility of cross-loading items and significant item covariance in the model. Initial results identified correlated error terms, which we specified in the revised model. After this adjustment, the results suggested an adequate fit to the data: [x2(2) = 381.2, p < 0.001], CFI = 0.845, AIC = 497.207, BIC = 647.136, RMSEA = 0.077 (RMSEA 90%CI = 0.062–0.091).

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These results indicate the presence of four valid factors in the MCQ-C; (1) positive meta-worry, (2) negative meta-worry, (3) SPR beliefs and (4) cognitive monitoring. 3.3. Internal consistency analysis We hypothesized that each subscale and the entire scale of the MCQ-C would evidence satisfactory internal consistency (reliability). The internal consistency of the MCQ-C was examined for the entire sample as well as separately for clinical and non-clinical participants. Coefficient alphas for the MCQ-C used in this investigation were 0.87 for the total scale, 0.86 for positive meta-worry, 0.75 for negative meta-worry, 0.64 for SPR beliefs and 0.75 for cognitive monitoring, respectively, for the entire sample. The average inter-item correlation for these obtained coefficient alpha estimates (entire sample) were 0.35 for the total scale, 0.50 for positive meta-worry, 0.34 for negative meta-worry, 0.21 for SPR beliefs and 0.33 for cognitive monitoring. For the clinical sample specifically, coefficient alphas were 0.89 for the total scale, 0.89 for positive meta-worry, 0.74 for negative meta-worry, 0.69 for SPR beliefs and 0.75 for cognitive monitoring. Average inter-item correlations for these coefficient alphas (clinical sample) were 0.39 for the total scale, 0.57 for positive meta-worry, 0.34 for negative meta-worry, 0.30 for SPR beliefs and 0.33 for cognitive monitoring. Coefficient alphas for the non-clinical sample were 0.71 for the total scale, 0.60 for positive meta-worry, 0.76 for negative metaworry, 0.58 for SPR beliefs and 0.74 for cognitive monitoring. Average inter-item correlations for these coefficient alphas (nonclinical sample) were 0.24 for the total scale, 0.29 for positive meta-worry, 0.21 for negative meta-worry, 0.19 for SPR beliefs and 0.37 for cognitive monitoring. Of note, coefficients for the MCQ-A were comparable to the MCQ-C (0.91 for the total scale, 0.88 for positive beliefs, 0.84 for uncontrollability and danger [negative meta-worry], 0.66 for SPR beliefs and 0.79 for cognitive self-consciousness [cognitive monitoring]) (Cartwright-Hatton et al., 2004) although they are somewhat higher when compared with the coefficients for the non-clinical sample in the current investigation. 3.4. Concurrent validity We proposed that participants’ scores on the MCQ-C would be significantly and positively associated with measures of internalizing symptoms (excessive worry and depression) and that these relationships would remain significant when excessive worry content was held constant. To investigate concurrent

Table 1 Correlations between the MCQ-C and the PSWQ-C and CDI for the entire sample. PSWQ-C Bivariate correlations MCQ-C positive meta-worry MCQ-C negative meta-worry MCQ-C cognitive monitoring MCQ-C SPR beliefs MCQ-C total score

0.21* 0.55** 0.30* 0.33** 0.48**

Partial correlations (worry excessiveness controlled) MCQ-C positive meta-worry 0.17 MCQ-C negative meta-worry 0.45** MCQ-C cognitive monitoring 0.21* MCQ-C SPR beliefs 0.25** MCQ-C total score 0.38** * **

p < 0.05. p < 0.01.

validity, Pearson product moment correlations were conducted utilizing the MCQ-C and measures of excessive worry (PSWQ-C) and depression (CDI) (reported in Table 1), with excessive worry content later included as a covariate. Each of the MCQ-C subscales and its total score were significantly and positively correlated with the measure of excessive worry. The only MCQ-C factor that was significantly and positively correlated with depression was negative meta-worry. Pearson correlations were also run for the clinical and non-clinical groups. For the clinical group, the results were almost identical, except that in addition to negative metaworry, cognitive monitoring was also significantly and positively correlated with depression (r = 0.33, p < 0.01). For the non-clinical group, there were no significant associations between MCQ-C factors and the CDI. However, for the non-clinical group, MCQ-C negative meta-worry and SPR beliefs both significantly and positively correlated with the PSWQ-C (r = 0.50, p < 0.05; r = 0.48, p < 0.05). To examine associations between these variables when controlling for age and excessive worry content, partial correlations were conducted. When controlling for excessive worry content, associations between the PSWQ-C and three MCQ-C factors (negative meta-worry, cognitive monitoring and SPR beliefs) remained significant when scores for the entire sample were analyzed. The same result emerged for the clinical sample. For the non-clinical sample, after controlling for excessive worry content, the PSWQ-C was significantly associated with two MCQC factors (negative meta-worry and SPR beliefs). With regard to depression, after controlling for excessive worry content, the only significant association that remained was between the CDI and negative meta-worry, for the clinical group (r = 0.19, p < 0.05). 3.5. Criterion validity We also hypothesized that participants with a diagnosis of an anxiety disorder would score significantly higher on the instrument than matched non-clinical participants, and that this difference would remain significant when excessive worry content was held constant. A one-way MANCOVA was conducted to examine differences between the clinical and non-clinical children on the four metacognitive variables of interest and internalizing symptoms after controlling for the effect of excessive worry content. To adjust for multiple comparisons, a bonferonni correction was applied and a significance level of 0.01 was used to evaluate results. The untransformed means and standard deviations for each study measure and the subscales of the MCQ-C for the clinical and non-clinical groups respectively are reported in Table 2. The overall main effect for group (clinical versus non-clinical) was significant using Pillai’s Trace; F(1, 95) = 3.11, p < 0.01. As expected, the clinical group reported higher levels of depression

CDI

0.04 0.36** 0.17* 0.13 0.25*

0.04 0.17 0.04 0.01 0.07

Table 2 Descriptive data across all measures for clinical and non-clinical participants. Measure

Clinical group (N = 78)

Non-clinical group (N = 20)

PSWQ-C CDI

22.37 (9.78) 10.08 (7.40)

16.60 (7.80) 5.35 (3.35)

MCQ-C total score Positive meta-worry Negative meta-worry SPR beliefs Cognitive monitoring

48.24 8.91 13.55 11.44 14.53

50.15 10.15 12.50 11.05 16.45

(12.76) (3.96) (4.27) (3.94) (4.32)

(8.56) (2.91) (4.11) (2.46) (4.02)

PSWQ-C = Penn State Worry Questionnaire for Children; CDI = Children’s Depression Inventory; MCQ-C = Metacognitions Questionnaire for Children; SPR Beliefs = Beliefs about Superstition, Punishment and Responsibility.

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and excessive worry than the non-clinical group. In terms of metacognitive processes, only one significant difference between groups was found utilizing the adjusted significance level. Contrary to what was expected, the non-clinical group scored higher than the clinical group on the cognitive monitoring subscale of the MCQ-C, F(4, 92) = 3.64, p < 0.01, after controlling for the effect of excessive worry content. 3.6. Age and gender analysis To obtain an initial picture of developmental patterns in metacognition in order to determine whether there were any associations between chronological age, gender and the metacognitive processes measured by the MCQ-C, a one-way MANCOVA was conducted using age as the covariate. This analysis examined gender differences in the four metacognitive processes while controlling for age. Data for the clinical and non-clinical groups are not reported separately here because age-group comparisons amongst the non-clinical group were not powerful enough to be conducted due to small sample size (N = 20); thus only results for the clinical group were analyzed. There was a significant interaction between age and gender for one outcome, the total score of the MCQ-C, F(1, 74) = 4.38, p < 0.05. More specifically, for younger children (one standard deviation below the mean age), there were no differences between girls and boys on the total score of the MCQ-C (Females: 44.27, Males: 47.27). For adolescents (one standard deviation above the mean age), however, girls (M = 55.37) scored significantly higher than boys (M = 45.76) on the MCQ-C, F(1, 74) = 5.06, p < 0.05. With regard to age differences in reports of metacognitive processes, the unstandardized regression coefficient between age and cognitive monitoring (b = 0.46, p < 0.01) was positive. This suggests that in this study, the older the child, the higher score he/she received on the cognitive monitoring subscale of the MCQ-C. 4. Discussion The results of this study suggest that the MCQ-C can be reliably used with child and adolescent clinical and non-clinical samples. Participants in this investigation endorsed a wide range of metacognitive beliefs measured by the MCQ-C, suggesting that the constructs captured by the instrument’s subscales are relevant for both children and adolescents. The internal reliability of the MCQ-C is acceptable and comparable to the MCQ-A. In addition, the replication of the four of five retained factors in the MCQ-C suggests a comparable factor structure to the MCQ-A. Initial support for concurrent validity of the MCQ-C was also found in the present study, as levels of MCQ-C beliefs were positively associated with self-reports of emotional symptoms. Further, it was anticipated that associations between participants’ scores on the MCQ-C and measures of emotional symptoms would be more clearly outlined when excessive worry content was controlled for. Notably, when excessive worry content was held constant, the positive relationship between the PSWQ-C and MCQ-C negative meta-worry, SPR beliefs and cognitive-monitoring for clinical participants remained, as well as associations between the PSWQ-C, negative meta-worry and SPR beliefs for non-clinical participants, suggesting that worry excessiveness was not accounting for these relationships. Children and adolescents with anxiety disorders who reported that they experience a high degree of worry (as measured by the PSWQC) also reported beliefs that worry is a highly negative experience, that thinking certain thoughts may have negative consequences, and that they closely monitor their cognitions. Positive beliefs

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about worry, on the other hand, were not linked to self-reports of excessive worry for either group when excessive worry content was held constant. This is in line with several studies in the adult literature that have documented a consistent relationship between negative meta-worry specifically and symptoms of generalized anxiety disorder (e.g., Wells, 2005). Wells and colleagues have also shown that positive meta-worry may not be as specific to anxiety (Cartwright-Hatton & Wells, 1997) and that most people to some degree have positive beliefs about worry. With excessive worry content partialled out, the only MCQ-C variable associated with depression was negative meta-worry, for the clinical group. The results of the correlational analyses between the MCQ-C and CDI for other metacognitive processes, however, suggest that the excessive aspect of youths’ worries primarily accounted for the association between depression and other metacognitive-processes (positive meta-worry, cognitive monitoring and SPR beliefs). As suggested by Papageorgiou and Wells (2000), positive beliefs about rumination may be more salient for depressed individuals than specific beliefs about worry or awareness of thoughts, and it is quite likely that for the primarily anxious children and adolescents in this sample, the metacognitive processes captured by the MCQ-C may have been more relevant for anxiety and worry than depressive symptomatology per se. The MCQ-C was able to distinguish between clinical and nonclinical youth on one of the four subscales (cognitive monitoring). Contrary to expectations, non-clinical participants reported greater awareness of thoughts than clinical participants on the MCQ-C. However, this same result was obtained by CartwrightHatton et al. (2004) in their initial investigation of the MCQ-A with adolescents (the non-clinical adolescents scored higher on positive beliefs and cognitive self-consciousness subscales, but not other subscales, of the MCQ-A); this pattern was also found in study with adults (Cartwright-Hatton & Wells, 1997). This consistent finding across children, adolescents and adults (in terms of cognitive monitoring) suggests that an awareness of monitoring one’s thoughts may not be sufficient to lead to anxiety problems. Research shows that increased awareness of thoughts does not invariably lead to maladaptive coping. Sica, Steketee, Ghisi, Chiri, and Franceschini (2007) found that cognitive self-consciousness and thought strategies aimed at distraction appeared to foster or facilitate adaptive coping styles in a sample of non-clinical undergraduate students. The authors suggest that mere awareness of thoughts (and attempts to do something about them) are not necessarily linked to psychopathology, noting that the negative aspects of cognitive monitoring are specifically linked to the excessive aspects of mental monitoring (e.g., a rigid and perseverative focus on one’s own thoughts, as in OCD; Janeck, Calamari, Riemann, & Heffelfinger, 2003). Of note, while the cognitive monitoring subscale of the MCQ-C explores an individual’s awareness of nonspecific thoughts (i.e., ‘‘I often notice the thoughts that I have in my head.’’) it does not assess awareness of anxious, intrusive, or repetitive thoughts, which may further explain why group differences were not found. It may also be possible that children without anxiety disorders are better able to focus their attention on non-worrisome thoughts than anxious children because their attention resources are not diverted to or consumed by threatening stimuli or anxious cognitions (Dalgeish et al., 2003). Furthermore, Cartwright-Hatton et al. (2004) suggest that youth with anxiety may wish to avoid thinking about their anxious cognitions and thus may be less, versus more aware of their thought processes. It is somewhat surprising, on the other hand, that clinical and non-clinical children did not differ in their reports of negative meta-worry and SPR beliefs on the MCQ-C.

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However, the SPR beliefs scale has been found to be only inconsistently associated with anxiety symptoms (CartwrightHatton & Wells, 1997; Wells & Papageorgiou, 1998) due to the heterogeneity of content on the SPR scale. This study did find age-related changes in the degree to which awareness of thoughts were reported in the clinical sample, suggesting that with increasing age, youth with anxiety disorders reported being increasingly aware of their thinking. This is consistent with previous research demonstrating that adolescents’ metacognitive abilities tend to be more advanced than younger children (Flavell, Green, & Flavell, 1998; Ormond, Luszcz, Mann, & Beswick, 1991). Interestingly, the authors of the MCQ-A (Cartwright-Hatton et al., 2004) did not find agerelated increases in self-reported metacognitive beliefs on their measure. Cartwright-Hatton et al. (2004) found that amongst a group of primarily non-clinical youth ages 13–17, the 13-yearolds received the highest scores on the MCQ-A. They suggest that perhaps these concepts are near fully developed by age 13, at least for adolescents without emotional disorders. However, in this study, the lack of significant age-related findings across the other subscales of the MCQ-C for youth with anxiety disorders suggests that these anxiety-specific metacognitive concepts (positive and negative meta-worry, SPR beliefs) were endorsed to the same extent by children and adolescents. This further demonstrates the value of examining these processes across a broader age range. Although cognitive processes such as rumination and worry may be less specific at younger ages because they are not fully crystallized, the expanded age range of children included in the present study also demonstrates that children as young as seven have at least some dysfunctional beliefs about their thoughts and worries and are able to comment upon these via a self-report measure. This lends support to the notion that young children’s developing metacognitive knowledge may enable them to reflect on their thoughts, a process that may be a prerequisite for the experience of worry (Vasey et al., 1994). With regard to gender differences in metacognitive processes, adolescent girls in the present study received higher scores on the total scale of the MCQ-C than adolescent boys, but there were no gender differences for younger children, nor were there any gender differences for specific subscales. It is not surprising that adolescent girls globally endorsed more metacognitive processes than boys, given previous findings that girls (particularly in adolescence) tend to display higher symptom levels of anxiety and depression as well as higher levels of rumination, worry and a negative attributional style than boys (Bernstein et al., 1996; Muris et al., 2004). Since gender differences in disorders associated with anxiety and worry tend to be heightened with increasing age, it is not surprising that gender differences in the metacognitive processes associated with worry would also be heightened among adolescents in particular. There are limitations to this study that should be considered when reviewing the pattern of results. First, the sample sizes of each group were relatively small and further studies should utilize a larger sample of non-patients as well as a broader range of ethnicities in both groups to enhance generalizability. Further, the current study piloted the use of the MCQ-C with children and adolescents and is the first to provide initial reliability and validity data for this measure. Additional studies with the MCQ-C are needed to replicate these findings and also provide test–retest reliability. Additional evidence of content validity should be provided. For example, although the content of the MCQ-items reflect the constructs of metacognition we hoped

to explore, these constructs themselves are quite abstract and therefore a self-report measure may not adequately address how children and adolescents understand their thoughts. The results of this study do, however, have important implications for future research. It appears that children as well as adolescents endorse metacognitive processes that may be linked to their experience of anxiety. The expanded age range of this study demonstrates that children as young as age seven report beliefs about metacognitive processes. This suggests that clinicians might consider exploring the metacognitive beliefs of their young clients. Attention to metacognitive beliefs is a central focus of a 6–12 session metacognitive therapy for adults (MCT; Wells, 2000) developed by Wells and colleagues. Further, Simons, Schneider, and Herpertz-Dahlman (2006) have recently utilized MCT with youth, piloting the treatment with 10 children and adolescents (ages 8–17) with OCD (5 of whom had comorbid diagnoses). In line with MCT, cognitive restructuring methods utilized in CBT with anxious children could be enhanced by targeting meta-worry and other metacognitive beliefs held by these youth. Alternatively, for children who lack awareness when they are engaged in anxious self-talk, greater emphasis on behavioral strategies such as exposure and relaxation may be warranted or specific metacognitive training in increasing awareness of thoughts (without paying excessive attention to them) for the purpose of challenging distortions in thinking may be beneficial. In order to bolster treatment effectiveness when teaching metacognitive skills in a developmentally appropriate way, therapists should have an accurate understanding of the normal level of metacognitive ability experienced by children of various ages (Vasey, 1993), particularly those with anxiety. Future research with anxious children could benefit from exploring whether different metacognitive processes are more typically endorsed by youth with particular anxiety disorder diagnoses (i.e., whether youth with GAD report more negative meta-worry than youth with other anxiety disorder diagnoses). Additional studies might also consider the metacognitive beliefs of children with depression as their primary problem. Future studies could also benefit from administering the MCQ-C prior to and after anxiety treatment, to track any changes that emerge as the result of CBT. It might also be useful to use qualitative, in addition to selfreport methods, of exploring these types of metacognitive processes in children and adolescents with and without internalizing disorders. In conclusion, the results of this study confirm the importance of cognitive factors, particularly, metacognitive factors in understanding childhood anxiety disorders. Determining the significance a child places on his/her intrusive thoughts can be useful in treatment, and as always, important differences in cognitive, social and emotional capacities displayed by youth at various developmental levels should be recognized. Although there is some continuity in the cognitive appraisals studied in adults from childhood to adolescence and even adulthood, the current research indicates that there are some interesting age and gender differences in the extent to which these beliefs are held.

Acknowledgements The authors wish to thank Tom Hildebrandt for help with statistical analysis and the John and Geraldine Weil Foundation for providing partial funding for this research.

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Appendix A. Metacognitions questionnaire-C We are interested in how young people think. Listed below are a number of beliefs that people have. Please read each item and say how much you generally agree with it by circling a number. Please respond to all the items. There are no right or wrong answers. Sex:. . .. . .. . . Age:. . .. . .. . . 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.

If I worry about things now, I will have fewer problems in the future It is not a good idea to worry because worrying is bad for me I often notice the thoughts that I have in my head I f I worry a lot, I could make myself sick When I am thinking about a problem in my head, I take note of how my mind works If I did not get a worry thought out of my head and then something bad happened, it would be my fault Worrying about things helps me to be organized and keep my stuff in order My worrying thoughts keep going, no matter how hard I try to put them out of my head When I am confused, worrying helps me sort things out I can’t stop thinking of the things that I worry about I try hard to keep track of the thoughts that I have in my head I should be able to tell myself to stop and start thinking about things whenever I want to Worrying might make me go crazy I am always thinking about the thoughts in my head I pay a lot of attention to the way that I think Worrying helps me feel better If I can’t stop my thoughts, I am no good Once I start worrying about something, I cannot stop If I can’t stop my thoughts, bad things will happen Worrying helps me solve problems It is bad to think about certain things If I couldn’t be in control of what I think, I would fall apart I need to worry in order to get my work done I think about my thoughts over and over

Do not agree 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Agree slightly 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

Agree moderately 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

Agree very much 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

Please ensure that you have responded to all items - Thank You.

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