Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2022 Mar 1.
Published in final edited form as: Cogn Behav Ther. 2020 Oct 19;50(2):104–120. doi: 10.1080/16506073.2020.1819866

THE MODERATING EFFECT OF AGE ON THE ASSOCIATIONS OF COGNITIVE AND METACOGNITIVE BELIEFS WITH PEDIATRIC OCD SYMPTOMS

Myles Rizvi a, Hannah Smilansky b, Rachel Porth b, Nicholas Myers c, Daniel Geller b, Brent J Small d, Joseph F McGuire c, Sabine Wilhelm b, Eric A Storch e
PMCID: PMC7897238  NIHMSID: NIHMS1626062  PMID: 33073722

Introduction

Cognitive and metacognitive models posit that beliefs are important to the development and maintenance of obsessive-compulsive disorder (OCD) (Rachman, 1997, 1998, 2002; Salkovskis, 1985, 1999; Wells, 1997, 2000; Salkovskis, 1985; Neal & Turner, 1991; Radomsky et al., 2014). According to these models, individuals with OCD over-interpret the meaning and significance of normative intrusive thoughts due to pre-existing dysfunctional beliefs, which then leads to escalation into obsessions. Beliefs discussed in these models have been conceptualized as falling into two categories: cognitive beliefs, which pertain to general or social beliefs, and metacognitive beliefs, which pertain to the meaning, power, and control of thoughts (Myers, Fisher, & Wells, 2008; Wells, 1997, 2000). Cognitive beliefs pertaining to exaggerated responsibility (i.e., one is able and obligated to prevent subjectively important negative events), overvalued importance of thoughts (i.e., the occurrence of thoughts implies they are meaningful and dangerous), control of thoughts (i.e., controlling thoughts is possible and necessary), overestimation of threat (i.e., exaggerated likelihood of severity and harm occurring), intolerance of uncertainty (i.e., certainty is necessary and ambiguity is intolerable), and perfectionism (i.e., imperfection and mistakes cannot be tolerated) have been found to be relevant to OCD symptoms in adults (Obsessive Compulsive Cognition Working Group [OCCWG], 2001, 2005; Myers, Fisher, & Wells, 2008; Wu & Carter, 2008; Gagné et al., 2017); Olatunji et al., 2018) and correlate with different symptom domains (e.g., Myers, Fisher, & Wells, 2008; Tolin, Woods, & Abramowitz, 2003). Metacognitive beliefs, which include positive and negative beliefs about worry (i.e., perceived benefits and negative consequences of worry, respectively), cognitive confidence (i.e., faith in one’s memory and attention), beliefs about the need to control thoughts (i.e., perceived consequences of not controlling thoughts), and cognitive self-consciousness (i.e., tendency to focus attention on thought processes), have also been found to be relevant to adult OCD symptoms (Cartwright-Hatton & Wells, 1997; Grøtte et al., 2016; Ramos-Cejudo, Salguero, & Cano-Vindel, 2013; Spada, Mohiyeddini, & Wells, 2008; Fergus & Bardeen, 2017; Cho, Jahng, & Chai, 2012; Sica et al., 2007; Yilmaz, Gençöz, & Wells, 2008).

Researchers have found that cognitive and metacognitive models of OCD are applicable to children and adolescents with the disorder (e.g., Reynolds & Reeves, 2008; Wilson & Hall, 2012). Coles et al. (2010) found that total scores on a child version of the Obsessional Beliefs Questionnaire (OCCWG, 2001, 2005), a measure of cognitive belief domains relevant to OCD, significantly correlated with self-reported OCD symptoms and trended toward being significantly correlated with clinician-rated OCD symptoms in youth aged 8–18 years with OCD. Schultz et al. (2018), found that children and adolescents with OCD obtained significantly higher scores than those without psychiatric disorders on total and domain-specific scores of a Danish version of the Obsessional Beliefs Questionnaire, Child Version (OBQ-CV; Coles et al., 2010) suggesting that cognitive beliefs relevant to adult OCD symptoms are similarly relevant to pediatric OCD symptoms. Research has also found that metacognitive beliefs are relevant to pediatric OCD symptoms, finding that metacognitive beliefs were significantly and positively correlated with self-reported OCD symptoms in non-clinical children and adolescents (Mather & Cartwright-Hatton, 2004; Esbjørn et al., 2013).

Differences in the clinical presentation of OCD have been observed in different age groups (e.g., Geller et al., 1998; Højgaard et al., 2016). Farrell and Barrett (2006) investigated developmental differences in the cognitive processing of threat in a sample of children, adolescents, and adults with OCD, finding that children with OCD reported experiencing fewer intrusive thoughts, which were less distressing and less controllable than those experienced by adolescents and adults with OCD. Additionally, adolescents and adults with OCD exhibited higher levels of responsibility attitudes, probability biases, and thought suppression strategies. A possible contributing factor to age differences in clinical presentation of OCD is insight. Children with OCD present with variable insight, where symptoms may be hidden and poorly articulated, and they may show compulsions without well-defined obsessions (Albanna, Bazaid, & Azeem, 2017; Selles et al., 2018; Lewin et al., 2010). Although children as young as 5 years display metacognitive understanding, their understanding of cognitive phenomena continues to develop throughout middle and later childhood (Bolton, 2004; Flavell, 1999). Difficulties youth and adolescents may have in identifying or articulating obsessions underlying their compulsions could suggest that cognitive and/or metacognitive beliefs are not as relevant in their clinical presentation, and that these beliefs may become more salient, or at least more recognizable, over time as a function of age.

Research examining the relationship between age and cognitive and metacognitive beliefs in OCD is limited and has yielded mixed results (Schultz et al., 2018; Myers, Solem, & Wells, 2019; Farrell, Waters, & Zimmer-Gembeck, 2012) which may indicate that some children struggle to understand, detect and report (meta) cognitive phenomena as a function of age and potentially clinical variables. Schultz et al. (2018), in their validation of a Danish version of the OBQ-CV, found that age influenced some OBQ-CV subscales negatively in nonclinical youths and positively in youths with anxiety disorders, although age did not significantly influence OBQ-CV scores in youths with OCD. However, the researchers speculated that the lack of a natural decline in OBQ-CV scores with age in youths with OCD might indicate a developmental trajectory of the pathology of OCD. Esbjørn et al. (2013), who investigated the psychometric properties of the 30-item MCQ-C in youth aged 9–17 years, found no significant difference in metacognitive belief scores between non-clinical children (aged 9–12) and adolescents (aged 13–17).

Myers, Solem, and Wells (2019), in a systematic review of the studies examining the psychometric properties of child and adolescent versions of the MCQ, found that studies examining the relationships between age and the MCQ-A total score and subscales (age range across studies 11–18) found either no or small relationships. Myers and colleagues suggested these findings supported the idea that metacognitions could become fully developed as early as 11 and remain stable throughout adolescence. Farrell, Waters, and Zimmer-Gembeck (2012), found that age moderated the relationship between the Metacognitions Questionnaire for Adolescents (MCQ-A; Cartwright-Hatton et al., 2004) scores and OCD symptom severity but only for adolescents (i.e., older than 11 years old) as opposed to younger children (i.e., less than 12 years old). The researchers noted that, while the age groups did not differ in overall symptom severity, the adolescent group evidenced significantly higher obsessional ratings of OCD, suggesting that OCD in adolescence is more likely to have a stronger obsessional component.

Our study intends to add to the existing literature by simultaneously examining the relations between cognitive and metacognitive beliefs to OCD symptoms in both children and adolescents with a primary diagnosis of OCD, and the moderating effect age may have on the relations between these factors. Few studies used clinician-rated measures of OCD when examining the relations between cognitive and metacognitive factors to OCD symptoms (i.e., Coles et al., 2010; Farrell et al., 2012); in this regard, our use of clinician-rated measures of OCD (i.e., CY-BOCS) in addition to self-report measures (e.g., OCI-CV) is a strength of our study, as it will allow us to extend the literature on the relations between these variables and clinician-rated OCD.

Our study had four primary aims. First, we investigated the relationship between cognitive belief domains (as measured by the OBQ-CV) and OCD symptom severity. Consistent with studies that used self-report scales (Coles et al., 2010) and clinician-rated measures (Schulz et al., 2018), we predicted that there would be a moderate positive relationship between OCD symptom severity and cognitive beliefs. Second, we investigated the relationship between metacognitive belief domains (as measured by the MCQ-C) and OCD symptom severity. Consistent with studies that used self-report scales (Esbjørn et al., 2013; Mather & Cartwright-Hatton, 2004) and clinician-rated measures (Farrell et al., 2012), we predicted that there would be a moderate positive relationship between OCD symptom severity and metacognitive beliefs. Third, we examined whether age moderated the relationship between cognitive belief domains and pediatric OCD symptom severity. In consideration of studies indicating that younger children with OCD tend to present with compulsions in the absence of well-articulated obsessions (e.g., Albanna, Bazaid, & Azeem, 2017), we predicted that age would positively moderate the relationship between cognitive beliefs and OCD symptom severity. Fourth, we examined whether age moderated the relationship between metacognitive belief domains and OCD symptom severity. Accordant to studies highlighting age differences in metacognitive beliefs in adolescents (Farrell et al., 2012), we predicted that age would positively moderate the relationship between metacognitive beliefs and OCD symptom severity. As a secondary aim, we compared cognitive and metacognitive belief domains between children and adolescents with OCD to expand upon the literature investigating age differences in these beliefs in pediatric OCD.

Method

Participants

Participants were 142 youths (ages 7–17) with a primary OCD diagnosis (CY-BOCS total score M = 24.78, SD = 5.86) who participated in a double-blind randomized controlled trial investigating the efficacy of D-cycloserine (DCS) augmentation for cognitive-behavioral therapy (CBT) for pediatric OCD (Storch et al., 2016), a two-site trial that took place at the University of South Florida in St. Petersburg, FL, and Massachusetts General Hospital in Boston, MA. The mean (SD) age of the participants was 12.7 (2.9) years. There were 76 females and 66 males in the cohort. Primary and comorbid diagnoses were ascertained by the Schedule for Affective Disorders and Schizophrenia for School Aged Children- Present and Lifetime version (K-SADS-PL; Kaufman & Schweder, 2004). Common comorbid diagnoses included generalized anxiety disorder (28.9%), social anxiety disorder (10.6%), attention-deficit/hyperactivity disorder (26%), depressive disorder (14.8%) and separation anxiety disorder (9.2%).

Procedure

Data pertaining to our variables of interest, namely baseline scores on cognitive and metacognitive belief self-report measures, and self-report and clinician-report measures of OCD symptoms, were obtained from the double-blind randomized controlled trial investigating the efficacy of D-cycloserine (DCS) augmentation for cognitive-behavioral therapy (CBT) for pediatric OCD (Storch et al., 2016). Raters were clinical psychology postdoctoral fellows or predoctoral students who were trained in measure administration by the 5th and last authors through didactics, reviewing videos, supervised observations, and finally rating certification. Ratings were audiotaped and a random selection was reviewed to ensure quality assurance. Weekly supervision was held at both the individual and cross site levels where ratings were reviewed and problems resolved (see Storch et al., 2016).

Measures

The CY-BOCS (Scahill, Riddle, McSwiggin-Hardin, et al., 1997) was used to measure participants’ OCD symptom severity. The CY-BOCS is a widely used and researched (Storch, Murphy, Geffken, et al., 2004, 2005; Scahill et al., 1997; Storch, Lewin, De Nadai, & Murphy, 2010) clinician-rated interview assessing OCD symptom severity.

The Obsessive-Compulsive Inventory—Child Version (OCI-CV; Foa et al., 2010) was used to measure participants’ OCD symptom dimensions. The OCI-CV is a 21-item self-report measure designed to assess varied OCD symptom dimensions. The OCI-CV consists of a total score and six subscales pertaining to specific symptom dimensions: Doubting/Checking, Obsessing, Hoarding, Washing, Ordering, and Neutralizing. The measure has been found to be a reliable and valid measure of OCD (Foa et al., 2010; Jones et al., 2013), and different language versions of the measure have also demonstrated reliability and validity (e.g., Martínez-González et al., 2015; Aspvall et al., 2020). According to the initial validation study (Foa et al., 2010), which used data from youths with OCD between the ages of 7–17, the total and subscale scores demonstrated strong internal consistency (α ≥ .81) and retest reliability (r ≥ .68), and no concerns were indicated regarding the readability of the measure. The OCI-CV demonstrated solid convergent validity as evidenced by significant correlations between the total score and clinician-rated levels of OCD symptoms as measured by the CY-BOCS Total (r = .31, p < .001) and Obsessions (r = .28, p < .01) and Compulsions (r = .28, p < .01) scores, and the NIMH Global Obsessive-Compulsive Scale (Insel et al., 1983; r = .23, p < .05). Additional support was found for the discriminant validity of the OCI-CV, as total scores were significantly more correlated with Multidimensional Anxiety Scale for Children (March, Parker, Sullivan, Stallings, & Conners, 1997) total scores than with Child Depression Inventory (Kovacs, 1985) total scores (z = 1.77, p = .04).

The Obsessional Belief Questionnaire—Child Version (OBQ-CV; Coles et al., 2010) was used to measure cognitive beliefs. The OBQ-CV is a 44-item self-report measure that assesses children’s OCD-related thoughts and beliefs across three domains: responsibility/threat, perfectionism/certainty, and importance/control of thoughts. Scores range from 44 to 176, with higher scores indicating more obsessive beliefs. According to the initial validation study (Coles et al., 2010), which used data from North American and Dutch pediatric OCD samples aged 9–17 and 8–18 respectively, the total and subscales of the OBQ-CV evidenced strong internal consistency (α = .96 for total score, .91 for Responsibility/Threat Estimation, .94 for Perfectionism/Certainty, and .91 for Importance/Control of Thoughts) and good retest reliability (r = .88 for total score, .84 for Responsibility/Threat Estimation, 0.81 for Perfectionism/Certainty, and .85 for Importance/Control of Thoughts), and no concerns were raised regarding the readability of the measure. The OBQ-CV also demonstrated solid convergent validity, correlating significantly with self-reported overall levels of OCD as measured by the Leyton Obsessional Inventory, Child Version (Berg, Rapoport, & Flament, 1986; r = .43, p < .05 ) OCD subscale of the Screen for Child Anxiety Related Emotional Disorders Revised (Vogt, King, & King, 2004; r = .37, p < .05) ; Revised Child Anxiety and Depression Scale, Child Version (Chorpita, Daleiden, Moffitt, Yim, & Umemoto, 2000; p < .001), and correlating (albeit borderline) with clinician-rated OCD symptoms as measured by the CY-BOCS (p = .05). The OBQ-CV was used to assess participants’ beliefs specific to OCD and was administered at the baseline visit.

The Metacognitions Questionnaire—Child Version (MCQ-C; Bacow et al., 2009) was used to measure metacognitive beliefs. The MCQ-C is a 24-item scale assessing metacognitive beliefs across four subscales: Positive Meta-Worry, Negative Meta-Worry, Cognitive Monitoring, and Superstition, Punishment, and Responsibility Beliefs. Scores range from 24 to 96, with higher scores indicating higher levels of metacognition. According to the initial development and validation study (Bacow et al., 2009), the MCQ-C demonstrated adequate internal consistency (α = .87 for total scale, .86 for Positive Meta-Worry, .75 for Cognitive Monitoring, and .64 for Superstition, Punishment, and Responsibility Beliefs) and some concurrent validity as it was significantly and positively associated with a self-report measure of excessive worry; however, adequate criterion validity was not demonstrated by the MCQ-C. Subsequent investigations of the psychometric properties of the MCQ-C (Smith & Hudson, 2013) similarly demonstrated adequate internal consistency for the total scale (α = .73), although all four subscales demonstrated poor reliability (α = .46 for Positive Meta-Worry, .64 for Negative Meta-Worry, .61 for Cognitive Monitoring, and .25 for Superstition, Punishment, and Responsibility Beliefs). Regarding the validity of the MCQ-C, Smith and Hudson found the measure demonstrated solid convergent validity, evidenced by significant correlations between other measures of internalizing symptoms, such as the Spence Children’s Anxiety Scale (Spence, 1997; r = .46, p < .01) and Strengths and Difficulties Questionnaire Emotional Problems Subscale (Goodman, 1997; r = .45, p < .01). The MCQ-C also demonstrated good discriminant validity, as evidenced by no significant correlation between the Strengths and Difficulties Questionnaire Conduct Problems Subscale, and good criterion validity, where children with anxiety disorders scored significantly higher on the total scale than non-clinical children (t[81] = −3.12, p = .002). However, concerns regarding the readability of the measure were noted by Smith and Hudson: qualitative analysis of the measure found in a small sample that six items were not understandable to children aged 7–8. The MCQ-C was used to assess participants’ total metacognitive thoughts and beliefs, and was also administered at the baseline visit.

Analytic plan

Cases who were missing >15% of data on any single measure were excluded from analyses (n = 32). For the remaining 110 cases, expectation maximization (EM) was used to impute data for cases for which data were missing (n = 14). EM utilizes a two-step iterative process based on the likelihood estimation of obtaining missing values (Peugh and Enders, 2004), providing accurate and efficient estimates for replacing missing data at the item level when less than 15% of item-level data are missing (Enders, 2003; Enders, 2010). Relationships between the cognitive belief domains (OBQ-CVand MCQ-C) and OCD symptom severity (CY-BOCS and OCI-CV) were examined using Pearson correlations. Cognitive and metacognitive belief domains (OBQ-CV and MCQ-C) between children (12 years of age and younger) and adolescents (13 years of age and older) were compared using independent-samples t-tests. Finally to test whether age moderated the relationships between cognitive and meta-cognitive beliefs and OCD symptom severity (CY-BOCS and OCI-CV), moderation analyses were conducted using the PROCESS macro for SPSS, version 3.3 (Hayes, 2018). All continuous predictors were mean-centered prior to analyses to prevent multicollinearity. To address heteroscedasticity, a heteroscedasticity-consistent standard error estimator (HC3, Davidson & MacKinnon, 1993) was employed, and moderation analyses were bootstrapped using 5000 samples to obtain 95% confidence intervals.

Results

Relationship Between Cognitive and Metacognitive Beliefs and OCD Severity.

Table 1 presents the correlation matrix for the OBQ-CV, MCQ-C, CY-BOCS, and OCI-CV. There were strong relationships between the self-reported OCI-CV total score and both the self-reported OBQ-CV total score (r = .69, p < .001) and the MCQ-C total score (r = .71, p < .001). Strong relationships were also found between the self-reported OCI-CV total score and both the self-reported OBQ-CV total score (r = .69, p < .001) and the MCQ-C total score (r = .71, p < .001).

Table 1.

Intercorrelations among the Obsessional Beliefs Questionnaire – Child Version, Metacognitions Questionnaire – Child Version, Children’s Yale-Brown Obsessive-Compulsive Scale, and the Obsessive Compulsive Inventory – Child Version.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1. OBQ Total 1
2. OBQ ITC .85*** 1
3. OBQ PC .91*** .61*** 1
4. OBQ RT .94*** .77*** .76*** 1
5. MCQ Total .72*** .62*** .63*** .71*** 1
6. MCQ PMW .51** .39*** .50*** .46*** .69*** 1
7. MCQ NMW .56*** .41** .50*** .58*** .81*** .34*** 1
8. MCQ CM .56*** .47*** .49*** .56*** .87*** .45*** .68*** 1
9. MCQ SPR .69*** .69*** .54*** .67*** .84*** .51*** .57*** .61*** 1
10. CY-BOCS Total .18 .14 .21* .13 .16 .06 .29** .06 .11 1
11. Compulsions .14 .12 .19 .08 .14 .05 .27** .05 .09 .93*** 1
12. Obsessions .20* .14* .21* .17 .16 .06 .28** .05 .12 .92*** .72*** 1
13. OCI-CV Total .69*** .56*** .58*** .73*** .71*** .50*** .57*** .61*** .59*** .11 .09 .12 1
14. Doubt/Checking .72*** .57*** .62*** .74*** .70*** .54*** .54*** .57*** .60*** .03 −.01 .07 .83*** 1
15. Hoarding .28** .17 .24* .34*** .26** .23* .21* .22* .19* .01 −.02 .05 .55*** .34*** 1
16. Neutralizing .35*** .31* .27*** .36*** .36*** .33*** .16 .34*** .33*** .09 .04 .14 .62*** .44*** .35*** 1
17. Obsessing .50*** .52*** .32* .56*** .60*** .21* .55*** .51*** .61*** .08 .08 .07 .61*** .49*** .13 .25** 1
18. Ordering .33*** .18 .36*** .31* .34*** .34*** .21* .31** .25** .09 .08 .09 .68*** .43*** .34*** .45*** .19 1
19. Washing .27** .19* .24* .24* .24* .16 .28** .24* .09 .12 .15 .06 .44*** .21* .11 .04 .00 .25*
Open in a new tab

Note.

*

p <.05,

**

p < .01,

***

p < .001; OBQ-CV = Obsessional Beliefs Questionnaire-Child Version, ITC = Importance of Thought Control, PC = Perfectionism and Intolerance of Uncertainty, RT = Responsibility and Threat Estimation, MCQ-C = Metacognitions Questionnaire – Child Version, PMW = Positive Meta-Worry, NMW = Negative Meta-Worry, CM = Cognitive Monitoring, SPR = Superstition, Punishment, and Responsibility, CY-BOCS = Children’s Yale-Brown Obsessive-Compulsive Scale, Compulsions = CY-BOCS Compulsion Severity Score, Obsessions = CY-BOCS Obsession Severity Score, OCI-CV = Obsessive Compulsive Inventory – Child Version.

Moderating Effects of Age on the Relationship Between Cognitive Beliefs and OCD Severity.

Moderation analyses were conducted to determine whether age moderated the relationship between cognitive and metacognitive beliefs and OCD severity. For the cognitive beliefs on the OBQ-CV, the overall moderation model accounted for only 3.46% of the variance in CY-BOCS total score [F(3, 106) = 1.06, p = .370] and age did not significantly moderate this relationship (see Table 2). Similarly for the MCQ-C, the overall model accounted for only 2.96% of the variance in CY-BOCS total score [F(3, 106) = 1.39, p = .249] and age did not moderate this relationship (see Table 2).

Table 2.

Conditional effect of Age on the relationship between Cognitive & Metacognitive Beliefs and Clinician-rated OCD Symptom Severity.

Predictor B 95% CI SE B t p
Cognitive Beliefs
  Constant 24.73 [23.52, 25.92] 0.63 39.32 <.001
  OBQ-CV 0.03 [−0.00, 0.06] 0.02 1.68 .095
  Age −0.06 [−0.47, 0.33] 0.21 −0.29 .773
  OBQ-CV*Age 0.00 [−0.01, 0.01] 0.01 0.25 .801
Predictor B 95% CI SE B t p
Metacognitive Beliefs
  Constant 24.65 [23.46, 25.80] 0.61 40.64 <.001
  MCQ-C 0.07 [−0.01, 0.15] 0.04 1.65 .101
  Age −0.06 [−0.45, 0.30] 0.19 −0.32 .750
  MCQ-C*Age 0.01 [−0.02, 0.04] 0.02 0.48 .629
Open in a new tab

Note. OBQ-CV = Obsessional Beliefs Questionnaire – Child Version, MCQ-C = Metacognitions Questionnaire – Child Version

Given the strong relationships observed between self-reported cognitive beliefs and self-reported OCD severity, the moderating effects of age on the relationship between cognitive and metacognitive beliefs and self-reported OCD severity was explored. For the cognitive beliefs on the OBQ-CV, the overall model was significant and accounted for 50.82% of the total variance in OCI-CV total scores [F(3,106) = 38.13, p < .001]. However, age did not moderate the predictive relationship between OBQ-CV total scores and OCI-CV total score [ΔF(1, 106) = 0.05, p = .818, ΔR2 <.001] (see Table 3). Similarly for metacognitive beliefs on the MCQ-C, the overall model was significant and accounted for 52.05% of the variance in OCI-CV scores [F(3, 106) = 68.54, p < .001]. However, the interaction between OBQ-CV total score and age was not significant [ΔF(1, 106) = 2.50, p = .117, ΔR2 = .01] (see Table 3), demonstrating that age did not moderate the relationship between the OBQ-CV total score and OCI-CV total score.

Table 3.

Conditional effect of Age on the relationship between Cognitive & Metacognitive Beliefs and Self-reported OCD Symptoms.

Predictor B 95% CI SE B t p
Constant 15.83 [14.87, 17.46] 0.62 25.33 <.001
OBQ-CV 0.13 [0.10, 0.16] 0.02 8.52 <.001
Age 0.48 [0.10, 1.00] 0.22 2.19 .031
OBQ-CV*Age −0.00 [−0.01, 0.01] 0.00 −0.23 .818
Predictor B 95% CI SE B t p
Metacognitive Beliefs
Constant 16.19 [14.99, 17.46] 0.64 25.16 <.001
MCQ-C 0.42 [0.33, 0.51] 0.05 9.01 <.001
Age 0.21 [−0.24, 0.65] 0.23 0.92 .362
MCQ-C*Age −0.02 [−0.05, 0.00] 0.01 −1.58 .117
Open in a new tab

Note. OBQ-CV = Obsessional Beliefs Questionnaire – Child Version, MCQ-C = Metacognitions Questionnaire – Child Version.

Comparison of Cognitive and Metacognitive Beliefs between Children and Adolescents.

Independent-samples t-tests compared cognitive and metacognitive beliefs between children and adolescents (see Table 4). For cognitive beliefs, adolescents had higher OBQ-CV total scores than children [t(108) = 2.61, p = .01, d = 0.50]. Adolescents also had higher scores for the Responsibility/Threat Estimation [t(108) = 2.45, p = .016, d = 0.47] and Perfectionism/Certainty [t(108) = 2.53, p = .013, d = 0.49] subscales, but not for the Importance/Control of Thoughts subscale [t(108) = 1.91, p = .058, d = 0.37].

Table 4.

Obsessive Beliefs and Metacognitive Beliefs among Children and Adolescents.

Total sample, N = 110 Adolescents, n = 62 Children, n = 48 t p d
Mean (SD) Mean (SD) Mean (SD)
Obsessive Beliefs
  OBQ-CV Total 114.03 (41.40) 122.86 (43.65) 102.63 (35.58) 2.61 .010 0.50
 Responsibility/Threat Estimation 42.79 (16.72) 46.15 (17.05) 38.46 (15.40) 2.45 .016 0.47
 Perfectionism/Certainty 43.98 (17.89) 47.68 (18.47) 39.19 (16.06) 2.53 .013 0.49
 Importance/Control of Thoughts 27.26 (11.15) 29.03 (12.52) 24.98 (8.68) 1.91 .058 0.37
Metacognitive Beliefs
  MCQ-C Total 48.26 (13.84) 52.47 (14.69) 42.82 (10.50) 3.85 <.001 0.74
 Positive Meta-Worry 8.78 (3.57) 9.95 (4.15) 7.27 (1.73) 4.19 <.001 0.81
 Negative Meta-Worry 14.01 (4.12) 14.60 (4.00) 13.25 (4.18) 1.72 .089 0.33
 Cognitive Monitoring 13.83 (4.90) 14.93 (5.19) 12.41 (4.12) 2.76 .007 0.53
 Superstition, Punishment, & Responsibility Beliefs 11.64 (4.51) 12.98 (4.76) 9.89 (3.49) 3.78 <.001 0.73
Open in a new tab

Note. OBQ-CV = Obsessive Beliefs Questionnaire – Child Version. MCQ-C = Metacognitions Questionnaire – Child Version.

Similarly, adolescents had higher MCQ-C total scores than children [t(108) = 3.85, p < .001, d = 0.74], as well as higher scores for the Positive Meta-Worry [t(108) = 4.19, p < .001, d = 0.81], Cognitive Monitoring [t(108) = 2.76, p = .007, d = 0.53], and Superstition, Punishment, and Responsibility Beliefs [t(108) = 3.78, p < .001, d = 0.73] subscales. However, no significant difference was observed for the Negative Meta-Worry subscale [t(108) = 1.72, p = .089, d = 0.33].

Discussion

Cognitive and metacognitive beliefs are salient to the development and maintenance of adult OCD, and our research suggests these beliefs are also involved in pediatric OCD. The first two hypotheses of our study posited OCD symptom severity would be moderately positively related to cognitive and metacognitive beliefs in consideration of previous findings (Coles et al., 2010; Esbjørn et al., 2013; Mather & Cartwright-Hatton, 2004). These hypotheses were partially supported with moderate relationships observed between cognitive and metacognitive beliefs and self-reported measures of OCD symptom severity. However, no positive relationships were observed between cognitive and metacognitive beliefs and clinician-rated measures of OCD symptom severity. These findings were consistent with past research demonstrating positive relationships between self-reported (but not clinician-rated) OCD symptom severity and cognitive beliefs (Coles et al., 2010), as well as past research demonstrating positive relationships between self-reported OCD symptom severity and metacognitive belief domains (Esbjørn et al., 2013; Mather & Cartwright-Hatton, 2004). On the one hand, these findings might reflect the subjective salience of cognitive and metacognitive beliefs to pediatric OCD. On the other hand, these findings may suggest that shared method variance is inflating relations between these beliefs and that the actual association is more modest in nature. The relationship could be attenuated due to the heterogeneity seen in pediatric OCD presentation; for example, some youth with more ‘Tourettic OCD’ may exhibit minimal cognitive beliefs linked to their symptoms.

Interestingly, we found no significant correlations between the total and subscale scores of the OCI-CV and total score of the CY-BOCS, contrary to the findings of the initial validation study (Foa et al., 2010). A recent examination of the validity and clinical utility of the measure (Aspvall et al., 2020) found small significant correlations between the measures at baseline and large significant correlations post-treatment, suggesting that symptom heterogeneity and measure design differences may have accounted for these findings. Specifically, the researchers noted the CY-BOCS, unlike the OCI-CV is designed such that the total symptom severity score is independent of the number and type of obsessions and compulsion, noting a patient with severe symptoms within a single OCD dimension would receive a low total score on the OCI-CV but could have a high total score on the CY-BOCs due to the possibility of rating these few symptoms as frequent and highly impairing. Heterogeneity in pediatric OCD may have similarly accounted for the absence significant correlations between the OCI-CV and CY-BOCS.

The third and fourth hypotheses of our study posited age would positively moderate the relationship between OCD symptom severity and cognitive and metacognitive beliefs. These hypotheses were not supported, suggesting the relevance of cognitive and metacognitive beliefs to pediatric OCD is not a function of age. These findings were unexpected, as we anticipated these beliefs would be more salient to older pediatric patients in consideration of past research highlighting age differences in symptom presentation (e.g., Geller et al., 2001) and metacognitive beliefs (e.g., Farrell et al., 2012). Interestingly, our study found that adolescents endorsed significantly higher overall levels of cognitive and metacognitive beliefs than children, specifically endorsing higher levels of cognitive beliefs relating to responsibility, threat estimation, perfectionism, and certainty; and higher levels of metacognitive beliefs relating to positive meta-worry, cognitive monitoring, and superstition, punishment, and responsibility beliefs. Despite significant age differences observed in experienced cognitive and metacognitive beliefs in pediatric OCD, the salience of cognitive and metacognitive beliefs may be moderated by the nature of the symptomatic presentation of OCD, irrespective of age. As noted, youth with OCD have heterogeneous symptom presentations that can include both symptoms involving fears (e.g., fear of contamination, fear of harming others) and non-pertinent to fears (e.g., ordering and symmetry urges), and we speculate other phenomena (e.g., sensory perfectionism) may be more important to the perpetuation of OCD symptoms non-pertinent to fears than cognitive and metacognitive beliefs.

Our study had some limitations. Our sample was primarily of White race/ethnicity, and results obtained in our research may not be generalizable to other racial/ethnic groups. Additionally, patients in our sample also had comorbid anxiety disorders (e.g., generalized anxiety disorder) that may have affected endorsements on self-reported measures of cognitive and metacognitive beliefs. Cognitive and metacognitive beliefs may not be specific to OCD (Libby, Reynolds, Derisley, & Clark, 2004; Reynolds & Reeves, 2008). Indeed, metacognition has been considered an important factor in the development and maintenance of a variety of psychological disorders (Wells & Matthews, 1996), especially generalized anxiety disorder (Wells, 2005). Third, the role of shared method variance must be considered when considering findings. Fourth, the OBQ-CV did not exclusively measure cognitive beliefs, as one belief domain (i.e., importance/control of thoughts) pertains more to metacognition, and this somewhat limits our ability to differentiate between these two belief categories. The overlap between cognitive and metacognitive beliefs highlights the importance of assessing these beliefs dimensionally rather than categorically. Fifth, limitations of the MCQ-C pertaining to belief measurement and comprehension may have affected endorsements of metacognitive beliefs. The MCQ-C does not measure cognitive confidence as measured by adult versions of the measure (i.e., MCQ-30), and six items of the measure were found to not be understandable to children aged 7–8 (Smith & Hudson, 2013), which may have similarly been hard to understand for younger children in our sample. Language can influence the ability to form and express beliefs, and our study would have benefitted from taking this variable into consideration. Finally, we were unable to examine the moderating effect of OCD symptom presentation (e.g., contamination, scrupulosity) on the relationship between cognitive and metacognitive beliefs and pediatric OCD symptom severity, which we highlight for future work. Cognitive and metacognitive beliefs may be more relevant to OCD symptoms involving fears rather than symptoms non-pertinent to fears, which may be better accounted for by other phenomena (e.g., sensory perfectionism).

In conclusion, our study suggests cognitive and metacognitive beliefs are relevant to pediatric OCD patients. However, this association is impacted by measurement approach and may be further influenced by OCD symptom dimensionality. The relationship between cognitive and metacognitive beliefs and pediatric OCD symptom severity was not moderated by age, suggesting these beliefs are clinically important to children and adolescent OCD cases alike. These findings have implications for assessment and treatment. Regarding assessment, clinicians are recommended to query cognitive and metacognitive beliefs for both younger and older youth alike. Regarding treatment with exposure and response prevention therapy (ERP), the gold-standard psychotherapy for OCD (McGuire et al., 2015), utilizing cognitive components to reinforce learning from exposures would be well advised (McGuire & Storch, 2018), particularly for adolescent patients in consideration of significantly higher endorsements on cognitive and metacognitive beliefs. Utilizing interventions designed to specifically modify metacognitive beliefs, such as metacognitive therapy (MCT; Wells, 2009), would also be advised in treating pediatric OCD. Indeed, a child adaptations of MCT has been developed and shown promise as an intervention for pediatric OCD (e.g., Michael, Schneider, & Herpertz-Dahlmann, 2006), and further research evaluating the efficacy of the intervention is warranted in consideration of the relevance of metacognitive beliefs to pediatric OCD. By understanding the relevance of cognitive and metacognitive beliefs to OCD symptoms in pediatric patients, clinicians are better able to craft ERP exercises that directly challenge these beliefs and maximize lessons learned, resulting in more clinically meaningful treatment of these patients.

Highlights.

  • Cognitive and metacognitive beliefs were significantly positively related to OCD symptom severity in children and adolescents with OCD.

  • Adolescents with OCD endorsed significantly higher levels of cognitive and metacognitive beliefs than children with OCD.

  • Age did not moderate the positive relationships observed between cognitive and metacognitive beliefs and pediatric OCD symptom severity.

  • Cognitive and metacognitive beliefs appear clinically relevant to pediatric OCD cases, highlighting the importance of assessing these beliefs to inform treatment.

Acknowledgments

This work was supported in part by grants to Dr. Geller (5R01MH093402) and Dr. Storch (1R01MH093381) from the National Institute of Mental Health. Opinions expressed in this article reflect those of the authors and are not necessarily reflective of those of the National Institute of Mental Health. Please address correspondence to Eric Storch, Ph.D., 1977 Butler Blvd, Suite 4-400, Baylor College of Medicine, Houston TX 77030. Eric.storch@bcm.edu.

Funding/Support

This work was supported by grants from the National Institute of Mental Health (NIMH) to Drs. Storch (1R01MH093381) and Geller (5R01MH093402). Role of the Sponsor: The funding organization was not involved in the design or conduct of the study; collection, management, analysis, and interpretation of the data or preparation, review, and approval of the manuscript.

Conflict of Interest

Dr. Storch receives research support from NIH, Agency for Healthcare Research and Quality, International OCD Foundation, and All Children’s Hospital Research Foundation. He has received royalties from Elsevier Publications, Springer Publications, American Psychological Association, Wiley, Inc, and Lawrence Erlbaum. Dr. Storch is on the Speaker’s Bureau and Scientific Advisory Board for the International OCD Foundation. Dr. Storch reports no other potential conflict of interest.

Dr. McGuire receives grant funding from the Tourette Association of America and National Institutes of Health. Dr. McGuire reports no other potential conflict of interest.

Dr. Small reports no financial disclosure and no potential conflict of interest.

Dr. Murphy reports research funding from Auspex Pharmaceuticals, National Institute of Mental Health, Shire Pharmaceuticals, Pfizer, Inc, F. Hoffmann-La Roche Ltd., AstraZeneca Pharmaceuticals, Centers for Disease Control, Massachusetts General Hospital, Sunovion Pharmaceuticals, Neurocrine Biosciences, PANDAS Network and Psyadon Pharmaceuticals. Dr. Murphy reports no other potential conflict of interest.

Dr. Wilhelm has received research support in the form of free medication and matching placebo from Forest Laboratories for a NIMH funded clinical trial. Dr. Wilhelm is a presenter for the Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies; she has received royalties from Elsevier Publications, Guilford Publications and New Harbinger Publications from Oxford University Press. Dr. Wilhelm has also received salary support from Novartis. Dr. Wilhelm has also received speaking honoraria from various academic institutions and foundations, including the International Obsessive Compulsive Disorder Foundation and the Tourette’s Syndrome Association. In addition, she received payment from the Association for Behavioral and Cognitive Therapies for her role as Associate Editor for the Behavior Therapy journal, as well as from John Wiley & Sons, Inc., for her role as Associate Editor on the journal Depression & Anxiety. Dr. Wilhelm reports no other potential conflict of interest.

Dr. Geller reports grant support from NIH and book honorarium from the American Academy of Child and Adolescent Psychiatry, speaking honoraria for Advanced Institute lectures from the American Academy of Child and Adolescent Psychiatry and Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies. Lifetime funding includes support from the Obsessive Compulsive Disorder Foundation, The Tourette Syndrome Association, The McIngvale Family Foundation, Eli Lilly, Pfizer, and Glaxo Smith Kline. Dr. Geller reports no other potential conflict of interest.

References

  1. Aspvall K, Cervin M, Andrén P, Perrin S, Mataix-Cols D, & Andersson E. (2020). Validity and clinical utility of the obsessive compulsive inventory – child version: Further evaluation in clinical samples. BMC Psychiatry, 20, 42. doi: 10.1186/s12888-020-2450-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bacow TL, Pincus DB, Ehrenreich JT, & Brody LR (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. [DOI] [PubMed] [Google Scholar]
  3. Berg CJ, Rapoport JL, & Flament M. (1986). The Leyton Obsessional Inventory-Child Version. Journal of the American Academy of Child Psychiatry, 25, 84–91. 10.1016/S0002-7138(09)60602-6 [DOI] [PubMed] [Google Scholar]
  4. Bocci L, & Gordon PK (2007). Does magical thinking produce neutralizing behaviour? An experimental investigation. Behaviour Research and Therapy, 45(8), 1823e1833. 10.1016/j.brat.2007.02.003. [DOI] [PubMed] [Google Scholar]
  5. Bolton D. (2004). Cognitive behavior therapy for children and adolescents: Some theoretical and developmental issues In Graham P. (Ed.), Cognitive behaviour therapy for children and families (2nd Ed, pp. 9–24). Cambridge, England: Cambridge University Press. doi: 10.1017/CBO9780511543845.002 [DOI] [Google Scholar]
  6. Cartwright-Hatton S, Mather A, Illingworth V, Brocki J, Harrington R. & Wells A. (2004). Development and preliminary validation of the Meta-cognition Questionnaire- Adolescent version. Journal of Anxiety Disorders, 18, 411–422. [DOI] [PubMed] [Google Scholar]
  7. 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. doi: 10.1016/S0887-6185(97)0001-X. [DOI] [PubMed] [Google Scholar]
  8. Cho Y, Jahng S, & Chai S. (2012). The factor structure and concurrent validity of the Korean version of the Metacognitions Questionnaire 30 (K-MCQ-30). Journal of Clinical Psychology, 68(3), 349–361. doi: 10.1002/jclp.20867 [DOI] [PubMed] [Google Scholar]
  9. Chorpita BF, Daleiden EL, Moffitt C, Yim L, & Umemoto LA (2000). Assessment of tripartite factors of emotion in children and adolescents I: Structural validity and normative data of an affect and arousal scale. Journal of Psychopathology and Behavioral Assessment, 22, 141–160. [Google Scholar]
  10. Coles ME, Wolters LH, Sochting I, de Haan E, Pietrefesa AS, & Whiteside SP (2010). Development and initial validation of the Obsessive Belief Questionnaire – Child Version (OBQ-CV). Depression and Anxiety, 27, 982–991. [DOI] [PubMed] [Google Scholar]
  11. Davidson & MacKinnon (1993) Estimation and inference in econometrics. Oxford: Oxford University Press. [Google Scholar]
  12. Enders CK (2003). Using the expectation maximization algorithm to estimate coefficient alpha for scales with item-level missing data. Psychological Methods, 8(3), 322–337. doi: 10.1037/1082-989X.8.3.322 [DOI] [PubMed] [Google Scholar]
  13. Enders CK, (2010). Applied missing data analysis. New York, NY, US: Guilford Press. [Google Scholar]
  14. Esbjørn BH, Sømhovd MJ, Holm JM, Lønfeldt NN, Bender PK, Nielsen SK, & Reinholdt-Dunne ML (2013). A structural assessment of the 30-item Metacognitions Questionnaire for Children and its relations to anxiety symptoms. Psychological Assessment, 25(4), 1211–1219. doi: 10.1037/a0033793 [DOI] [PubMed] [Google Scholar]
  15. 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(1), 95–114. [DOI] [PubMed] [Google Scholar]
  16. Farrell LJ, Waters AM, & Zimmer-Gembeck MJ (2012). Cognitive biases and obsessive- compulsive symptoms in children: Examining the role of maternal cognitive bias in child age. Behavior Therapy, 43, 593–605. doi: 10.1016/j.beth.2011.10.003 [DOI] [PubMed] [Google Scholar]
  17. Fergus TA, & Bardeen JR (2017). The Metacognitions Questionnaire-30: An examination of a bifactor model and measurement invariance among men and women in a community sample. Assessment, 1–12. doi: 10.1177/1073191116685807 [DOI] [PubMed] [Google Scholar]
  18. Flavell JH (1999). Cognitive development: Children’s knowledge about the mind. Annual Review of Psychology, 50, 21–45. [DOI] [PubMed] [Google Scholar]
  19. Foa EB, Coles M, Huppert JD, Pasupeleti RV, Franklin MF, & March J. (2010). Development and validation of a child version of the Obsessive Compulsive Inventory. Behavior Therapy, 41(1), 121–132. [DOI] [PubMed] [Google Scholar]
  20. Gagné J, Van Kirk N, Hernandez-Vallant A, Potluri S, Krompinger JW, Cattie JE, Garner LE, Crosby JM, Brennan BP, & Elias JA (2017). Validating an abbreviated version of the Obsessive Beliefs Questionnaire. Journal of Clinical Psychology, 74, 1791–1807. doi: 10.1002/jclp.22629 [DOI] [PubMed] [Google Scholar]
  21. Geller D, Biederman J, Faraone S, Agranat A, Cradock K, Hagermoser L, Grace K, Frazier J, & Coffey B. (2001). Developmental aspects of obsessive compulsive disorder: Findings in children, adolesents, and adults. The Journal of Nervous and Mental Disease, 189(7), 471–477. [DOI] [PubMed] [Google Scholar]
  22. Geller D, Biederman J, Jones J, Park K, Schwartz S, Shapiro S, & Coffey B. (1998). Is juvenile obsessive-compulsive disorder a developmental subtype of the disorder? A review of the pediatric literature. Journal of the American Academy of Child and Adolescent Psychiatry, 37(4), 420–427. doi: 10.1097/00004583-199804000-00020 [DOI] [PubMed] [Google Scholar]
  23. Goodman R. (1997). The Strengths and Difficulties Questionnaire: A research note. Journal of Child Psychology and Psychiatry, 38, 581–586. [DOI] [PubMed] [Google Scholar]
  24. Grøtte T, Solem S, Myers SG, Hjemdal O, Vogel PA, Güzey IC, Hansern B, Nordahl HM, & Fisher P. (2016). Metacognitions in obsessive-compulsive disorder: A psychometric study of the Metacognitions Quesionnaire-30. Journal of Obsessive-Compulsive and Related Disorders, 11, 82–90. [Google Scholar]
  25. Hayes AF (2018). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. Guilford Publications. [Google Scholar]
  26. Højgaard DRMA, Mortensen EL, Ivarsson T, Hybel K, Skarphedinsson G, Nissen JB, Valderhaug R, Dahl K, Weidle B, Torp NC, Grados M, Lewin AB, Melin KH, Storch EA, Wolters LH, Murphy TK, Sonuga-Barke EJS, & Thomsen PH (2017). Structure and clinical correlates of obsessive-compulsive symptoms in a large sample of children and adolescents: a factor analytic study across five nations. European Child & Adolescent Psychiatry, 26(6), 681–689. doi: 10.1007/s00787-016-0887-5 [DOI] [PubMed] [Google Scholar]
  27. Insel TR, Murphy DL, Cohen RM, Alterman I, Kilton C, & Linnoila M. (1983). Obsessive-compulsive disorder:A double-blind trial of clompiramine and clorgyine.Archives of General Psychiatry, 40, 605–612. [DOI] [PubMed] [Google Scholar]
  28. Jones AM, de Nadai AS, Arnold EB, McGuire JF, Lewin AB, Murphy TK, & Storch EA (2013). Psychometric properties of the Obsessive Compulsive Inventory: Child Version in children and adolescents with obsessive–compulsive disorder. Child Psychiatry and Human Development, 44(1), 137–151. Doi: 10.1007/s10578-012-0315-0 [DOI] [PubMed] [Google Scholar]
  29. Kaufman J, & Schweder AE (2004). The Schedule for Affective Disorders and Schizophrenia for School-Age Children: Present and Lifetime version (K-SADS-PL) In Hilsentroth MJ & Segal DL (Eds.) Comprehensive handbook of psychological assessment, Vol. 2, Personality assessment (pp. 247–255). John Wiley & Sons Inc. [Google Scholar]
  30. Kovacs M. (1985). The Children’s Depression Inventory (CDI). Psychopharmacology Bulletin, 21, 995–998. [PubMed] [Google Scholar]
  31. Lewin AB, Bergmann RL, Peris TS, Chang S, McCracken JT, & Piacentini J. (2010). Correlates of insight among youth with obsessive-compulsive disorder. Journal of Psychology and Psychiatry, 51(5), 603–611. doi: 10.1111/j.1469-7610.2009.0218.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. March JS, Parker JDA, Sullivan K, Stallings P, & Conners K. (1997). The Multidimensional Anxiety Scale for Children (MASC): Factor structure, reliability, and validity. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 554–565. [DOI] [PubMed] [Google Scholar]
  33. Martínez-González AE, Rodríguez-Jiménez T, Piqueras JA, Vera-Villarroel, & P., Godoy A. (2015) Psychometric Properties of the ObsessiveCompulsive Inventory-Child Version (OCI-CV) in Chilean Children and Adolescents. PLOS One 10(8). doi: 10.1371/journal.pone.0136842 [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. 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(4), 743–749. [DOI] [PubMed] [Google Scholar]
  35. McGuire JF, Piacentini J, Lewin AB, Brennan EA, Murphy TK, & Storch EA (2015). A meta-analysis of cognitive behavior therapy and medication for child obsessive compulsive disorder: Moderators of treatment efficacy, Response, and Remission. Depression and Anxiety, 32(8), 580–593. doi: 10.1002/da.22389 [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. McGuire JF, & Storch EA (Accepted/In press – January 1, 2018). An inhibitory learning approach to cognitive-behavioral therapy for children and adolescents. Cognitive and Behavioral Practice. 10.1016/j.cbpra.2017.12.003 [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Myers SG, Fisher PL, & Wells A. (2008). Belief domains of the Obsessive Beliefs Questionnaire-44 (OBQ-44) and their specific relationship with obsessive-compulsive symptoms. Journal of Anxiety Disorders, 22, 475–484. [DOI] [PubMed] [Google Scholar]
  38. Myers SG, Fisher PL, & Wells A. (2009). An empirical test of the metacognitive model of obsessive-compulsive symptoms: fusion beliefs, beliefs about rituals, and stop signals. Journal of Anxiety Disorders, 23, 436–442. [DOI] [PubMed] [Google Scholar]
  39. Myers SG, Solem S, & Wells A. (2019). The Metacognitions Questionnaire and its derivatives in children and adolescents: A systematic review of psychometric properties. Frontiers in Psychology, 10, 1871. doi: 10.3389/fpsyg.2019.01871 [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Myers SG, & Wells A. (2013). An experimental manipulation of metacognition: A test of the metacognitive model of obsessive compulsive symptoms. Behaviour Research and Therapy, 51, 177–184. doi: 10.1016/j.brat.2013.01.007 [DOI] [PubMed] [Google Scholar]
  41. Neal AM, & Turner SM (1991). Anxiety disorder research with African Americans: Current status. Psychology Bulletin, 109, 400–410. [DOI] [PubMed] [Google Scholar]
  42. Obsessive Compulsive Cognition Working Group. (2001). Development and initial validation of the Obsessive Beliefs Questionnaire and the Interpretation of Intrusions Inventory. Behavioural Research and Therapy, 39, 987–1006. [DOI] [PubMed] [Google Scholar]
  43. Obsessive Compulsive Cognition Working Group. (2005). Psychometric validation of the Obsessive Beliefs Questionnaire and the Interpretation of Intrusions Inventory: Part 2: Factor analyses and testing of a brief version. Behaviour Research and Therapy, 43, 1527–1542. [DOI] [PubMed] [Google Scholar]
  44. Olatunji BO, Ebesutani C, & Tolin DF (2018, October 11). A bifactor model of obsessive beliefs: Specificity in the prediction of obsessive-compulsive disorder symptoms. Psychological Assessment. Advanced online publication. 10.1037/pas0000660 [DOI] [PubMed] [Google Scholar]
  45. Peugh JL, & Enders CK (2004). Missing Data in Educational Research: A Review of Reporting Practices and Suggestions for Improvement. Review of Educational Research, 74(4), 525–556. doi: 10.3102/00346543074004525 [DOI] [Google Scholar]
  46. Rachman S. (1997). A cognitive theory of obsessions. Behaviour Research and Therapy, 35, 793–802. [DOI] [PubMed] [Google Scholar]
  47. Rachman S. (1998). A cognitive theory of obsessions: Elaborations. Behaviour Research and Therapy, 36, 385–401. doi: 10.1016/S0005-7967(97)10041-9 [DOI] [PubMed] [Google Scholar]
  48. Rachman S. (2002). A cognitive theory of compulsive checking. Behaviour Research and Therapy, 40, 625–639. doi: 10.1016/S0005-7967(01)00028-6 [DOI] [PubMed] [Google Scholar]
  49. Radomsky AS, Alcolado GM, Abramowitz JS, Alonso P, Belloch A, Bouvard M, Clark DA, Coles ME, Doron G, Fernández-Álvarez H, Garcia-Soriano G, Ghisi M, Gomez B, Inozu M, Mouldin R, Shams G, Sica C, Simos G, & Wong W. (2014). Part 1 – You can run but you can’t hide: Intrusive thoughts on six continents. Journal of Obsessive-Compulsive and Related Disorders, 3, 269–279. doi: 10.1016/j.jocrd.2013.09.002 [DOI] [Google Scholar]
  50. Ramos-Cejudo J, Salguero JM, & Cano-Vindel A. (2013). Spanish version of the Meta-Cognitions Questionnaire 30 (MCQ-30). Spanish Journal of Psychology, 16, 1–8. doi: 10.1017/sjp.2013.95 [DOI] [PubMed] [Google Scholar]
  51. Rassin E, Merckelbach H, Muris P, & Spaan V. (1999). Thought-action fusion as a causal factor in the development of intrusions. Behaviour Research and Therapy, 37(3), 231–237. 10.1016/S0005-7967(98)00140-5. [DOI] [PubMed] [Google Scholar]
  52. Reynolds S, & Reeves J. (2008). Do cognitive models of obsessive compulsive disorder apply to children and adolescents? Behavioural and Cognitive Psychotherapy, 36(4), 463–471. [Google Scholar]
  53. Salkovskis PM (1985). Obsessional-compulsive problems: A cognitive-behavioural analysis. Behaviour Research and Therapy, 23, 571–583. [DOI] [PubMed] [Google Scholar]
  54. Salkovskis PM (1999). Understanding and treating obsessive-compulsive disorder. Behaviour Research and Therapy, 37, S29–S52. doi: 10.1016/S0005-7967(99)00049-2 [DOI] [PubMed] [Google Scholar]
  55. Scahill L, Riddle MA, McSwiggin-Hardin M, & Ort SI (1997). Children’s Yale-Brown obsessive-compulsive scale: Reliability and validity. Journal of the American Academy of Child Psychiatry, 36, 844–852. [DOI] [PubMed] [Google Scholar]
  56. Schultz C, Lambek R, Højgaard D, Söchting I, Thastum M, Thomsen PH, & Hybel KA (2018). Psychometric validation of a Danish version of the Obsessive Beliefs Questionnaire – Child Version (OBQ-CV). Nordic Journal of Psychiatry. Advance online publication. doi: 10.1080/08039488.2018.1513068 [DOI] [PubMed] [Google Scholar]
  57. Selles RR, Højgaard DRMA, Ivarsson T, Thomsen PH, McBride N, Storch EA, Geller D, Wilhelm S, Farrell LJ, Waters AM, Mathieu S, Lebowitz E, Elgie M, Soreni N, & Stewart SE (2018). Symptom insight in pediatric obsessive-compulsive disorder: Outcomes of an international aggregated cross-sectional sample. Journal of the American Academy of Child and Adolescent Psychiatry, 57(8), 615–619. doi: 10.1016/j.jaac.2018.04.012 [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. Sica C, Steketee G, Ghisi M, Chiri LR, & Franceschini S. (2007). Metacognitive beliefs and strategies predict worry, obsessive-compulsive symptoms and coping styles: A preliminary prospective study on an Italian non-clinical sample. Clinical Psychology and Psychotherapy, 14(4), 258–268. doi: 10.1002/c [DOI] [Google Scholar]
  59. Simons M, Schneider S, & Herpertz-Dahlmann B. (2006). Metacognitive therapy versus exposure and response prevention for pediatric obsessive-compulsive disorder. A case series with randomized allocation. Psychotherapy and Psychosomatics, 75(4). 257–264. doi: 10.1159/000092897 [DOI] [PubMed] [Google Scholar]
  60. Smith KE, & Hudson JL (2013). Metacognitive beliefs and processes in clinical anxiety in children. Journal of Clinical Child & Adolescent Psychology, 42(2), 590–602. doi: 10.1080/15374416.2012.755925 [DOI] [PubMed] [Google Scholar]
  61. Solem S, Myers SG, Fisher PL, Vogel PA, & Wells A. (2010). An empirical test of the metacognitive model of obsessive-compulsive symptoms: Replication and extension. Journal of Anxiety Disorders, 24, 79–86. doi: 10.1016/j.janxdis.2009.08.009 [DOI] [PubMed] [Google Scholar]
  62. Spada MM, Mohiyeddini C, & Wells A. (2008). Measuring metacognitions associated with emotional distress: Factor structure and predictive validity of the Metacognitions Questionnaire 30. Personality and Individual Differences, 45, 238–242. doi: 10.1016/j.paid.2008.04.005 [DOI] [Google Scholar]
  63. Spence SH (1997). Structure of anxiety symptoms among children: A confirmatory factor-analytic study. Journal of Abnormal Psychology, 106, 280–297. [DOI] [PubMed] [Google Scholar]
  64. Storch EA, Lewin AB, De Nadai, & Murphy TK (2010). Defining treatment response and remission in obsessive-compulsive disorder: A signal detection analysis of the Children’s Yale-Brown Obsessive Compulsive Scale. Journal of the American Academy of Child and Adolescent Psychiatry, 49(7), 708–717. [DOI] [PubMed] [Google Scholar]
  65. Storch EA, Murphy TK, Geffken GR, Bagner DM, Soto O, Sajid M, Allen P, Roberti JW, Killiany EM, & Goodman WK (2004). Psychometric evaluation of the Children’s Yale-Brown Obsessive-Compulsive Scale. Psychiatry Research, 129(1), 91–98. [DOI] [PubMed] [Google Scholar]
  66. Storch EA, Murphy TK, Geffken GR, Bagner DM, Soto O, Sajid M, Allen P, Killiany EM, & Goodman WK (2005). Factor analytic study of the Children’s Yale-Brown Obsessive-Compulsive Scale. Journal of Clinical Child and Adolescent Psychology, 34(2), 312–319. [DOI] [PubMed] [Google Scholar]
  67. Storch EA, Wilhelm S, Sprich S, Henin A, Micco J, Small BJ, McGuire J, Mutch PJ, Lewin AB, Murphy TK, & Geller DA (2016) Efficacy of augmentation of cognitive behavior therapy with weight-adjusted D-cycloserine vs placebo in pediatric obsessive-compulsive disorder: A randomized clinical trial. Journal of American Medical Association Psychiatry, 73(8), 779–788. doi: 10.1001/jamapsychiatry.2016.1128 [DOI] [PMC free article] [PubMed] [Google Scholar]
  68. Tolin DF, Woods CM, & Abramowitz JS (2003). Relationship between obsessive beliefs and obsessive-compulsive symptoms. Cognitive Therapy and Research, 27, 657–669. [Google Scholar]
  69. Vogt DS, King DW, & King LA (2004). Focus groups in psychological assessment: Enhancing content validity by consulting members of the target population. Psychological Assessment, 16, 231–243. [DOI] [PubMed] [Google Scholar]
  70. Wells A. (1995). Meta-cognition and worry: A cognitive model of generalized anxiety disorder. Behavioural and Cognitive Therapy, 23, 301–320. doi: 10.1017/S1352465800015897 [DOI] [Google Scholar]
  71. Wells A. (1997). Cognitive therapy of anxiety disorders: A practice manual and conceptual guide. Chichester, UK: Wiley. [Google Scholar]
  72. Wells A. (2000). Emotional disorders and metacognition: Innovative cognitive therapy. Chichester, UK: Wiley. [Google Scholar]
  73. Wells A. (2004). A cognitive model of GAD: Metacognitions and pathological worry In Heimberg RG, Turk CL, & Mennin DS (Eds.), Generalized anxiety disorder: Advances in research and practice (pp.164–186). New York, NY: Guilford Press. [Google Scholar]
  74. Wells A. (2005). The meta-cognitive model of GAD: assessment of meta-worry and relationship with DSM-IV generalized anxiety disorder. Cognitive Therapy and Research, 29, 107–121. [Google Scholar]
  75. Wells A. (2009). Metacognitive Therapy for Anxiety and Depression. New York, NY; London: Guilford Press. [Google Scholar]
  76. Wells A, & Cartwright-Hatton S. (2004). A short form of the Metacognitions Questionnaire: Properties of the MCQ-30. Behavior Research and Therapy, 42(4), 385–396. doi: 10.1016/S0005-7967(03)00147-5 [DOI] [PubMed] [Google Scholar]
  77. Wells A, & Mathews G. (1996). Modelling cognition in emotional disorder: The S-REF model. Behavior Research and Therapy, 34, 881–888. [DOI] [PubMed] [Google Scholar]
  78. Wilson C, & Hall M. (2012). Thought control strategies in adolescents: Links with OCD symptoms and meta‐cognitive beliefs. Behavioural and Cognitive Psychotherapy, 40, 438–451. [DOI] [PubMed] [Google Scholar]
  79. Wu KD, & Carter SA (2008). Further investigation of the Obsessive Beliefs Questionnaire: Factor structure and specificity of relations with OCD symptoms. Journal of Anxiety Disorders, 22, 824–836. [DOI] [PubMed] [Google Scholar]
  80. Yilmaz AE, Gençöz T, & Wells A. (2008). Psychometric characteristics of the Penn State Worry Questionnaire and Metacognitions Questionnaire-30 and metacognitive predictors of worry and obsessive-compulsive symptoms in a Turkish sample. Clinical Psychology and Psychotherapy, 15(6), 424–439. doi: 10.1002/cpp.589 [DOI] [PubMed] [Google Scholar]

RESOURCES