Applied Neuropsychology: Child

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/hapc20

Feasibility and potential benefits of an attention

and executive function intervention on
metacognition in a mixed pediatric sample

Sarah J. Macoun , Sarah Pyne , Jennifer MacSween , Jessica Lewis & John
Sheehan

To cite this article: Sarah J. Macoun , Sarah Pyne , Jennifer MacSween , Jessica Lewis &
John Sheehan (2020): Feasibility and potential benefits of an attention and executive function
intervention on metacognition in a mixed pediatric sample, Applied Neuropsychology: Child, DOI:
10.1080/21622965.2020.1794867

To link to this article: https://doi.org/10.1080/21622965.2020.1794867

Published online: 23 Jul 2020.

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APPLIED NEUROPSYCHOLOGY: CHILD
https://doi.org/10.1080/21622965.2020.1794867

Feasibility and potential benefits of an attention and executive function

intervention on metacognition in a mixed pediatric sample
Sarah J. Macoun, Sarah Pyne, Jennifer MacSween, Jessica Lewis, and John Sheehan
Psychology Department, University of Victoria, Victoria, British Columbia, Canada

ABSTRACT KEYWORDS
The term “metacognition” describes thinking about a cognitive phenomenon or, more simply put, Attention; children;
thinking about thinking . Metacognition involves using knowledge about one’s cognitive processes cognitive rehabilitation;
to change behavior, including monitoring and controlling cognition. Metacognition is vital for executive function;
metacognition
learning and is often more difficult for children with neurodevelopmental concerns (e.g. Attention
Deficit Hyperactivity Disorder [ADHD], Fetal Alcohol Spectrum Disorder [FASD], Autism Spectrum
Disorders [ASD]), possibly due to underlying deficits in attention and executive functioning (EF).
The present study evaluated a 6- to 8-week cognitive intervention aimed at improving attention
and EF and children’s metacognitive abilities. Participants included a mixed sample of 50 children
ages 6–12 years presenting with attention and/or EF deficits. Children within the active interven-
tion group completed a game-based attention/EF intervention called Caribbean Quest (CQ), which
combines process-specific and compensatory approaches to remediate attention and EF.
Educational Assistants (EAs) supported children during gameplay by teaching explicit metacogni-
tive strategies. Pre/post assessments included measures of attention and working memory (WM),
metacognitive awareness (child, parent, and EA questionnaires), and metacognitive regulation
(metacognitive monitoring and control). Results indicated post-intervention gains in WM, metacog-
nitive awareness, and metacognitive regulation (self-monitoring and metacognitive control). These
results provide preliminary support for CQ as potentially beneficial in improving aspects of EF and
metacognition in children.

Most individuals have experienced the “tip of the tongue”
phenomenon, or a failure to recall a word despite prior
knowledge and a feeling that retrieval is imminent (Esken,
2012). This sense of “knowing what we know” is an example
of what Anne Brown (1978) and John Flavell (1979) coined
as “metacognition” to describe, simply put, thinking about
thinking. Metacognition refers to a group of abilities that
enable one to reflect upon their own cognitive processes and
adapt their behavior to meet their goals. Largely stemming
from earlier frameworks (Brown, 1978; Flavell, 1979), con-
temporary theories typically parse the construct into two
broad domains, declarative and procedural metacognition,
although terminology differs (Destan et al., 2017; Fernandez-
duque et al., 2000; Kuhn, 2000; Leary & Sloutsky, 2017;
Oguz & Sahin, 2011; Roebers, 2017; Roebers & Spiess, 2017;
Schneider, 2008; Veenman et al., 2006). Declarative meta-
cognition refers to one’s knowledge about cognitive and
learning processes (e.g. understanding oneself as a learner
and the factors that influence learning; Destan et al., 2017;
Roebers, 2017), while procedural metacognition refers to the
processes involved in monitoring one’s cognitive perform-
ance and controlling cognitive activities to achieve specific
goals (Destan et al., 2017; Roebers, 2017; Tamm et al.,
2014). The subcomponents of procedural metacognition,
monitoring, and controlling, are thought to influence each
other through feedforward and feedback loops, with moni-
toring also being a precondition for control (Leary &
Sloutsky, 2017; Roebers, 2017; Roebers & Feurer, 2016).
Declarative metacognition (metacognitive knowledge) is
often assessed off-line through self-reports, interviews, and
observations, whereas procedural metacognition (monitoring
and control) is often assessed via on-line measures of moni-
toring (judgments of learning, confidence judgments, judg-
ments of performance) and control (allocation of study
time, error correction, etc.; Feitler & Hellekson, 1993; Jacobs
& Paris, 1987; Manning et al., 1996; Roebers et al., 2014;
Schmitt, 1990; Sperling et al., 2002; Swanson, 1990;
Zimmerman & Martinez-Pons, 1986; Zimmerman &
Martinez-Pons, 1988). An alternate measurement approach
for procedural metacognition involves examining post-error
slowing, referring to a phenomenon whereby, after detecting
an error, individuals tend to slow their response speed to
improve accuracy (Dutilh et al., 2012; Holroyd & Coles,
2002; Krusch et al., 1996; Ornstein et al., 2009; Ullsperger &
Von Cramon, 2006).
Executive functioning (EF) is another umbrella term that
refers to a group of top-down cognitive processes that
enable one to adaptively react to novel and/or complex

CONTACT Sarah J. Macoun sjmacoun@uvic.ca Department of Psychology, University of Victoria, Victoria, British Columbia, Canada.
Supplemental data for this article can be accessed at publisher’s website.
ß 2020 Taylor & Francis Group, LLC
2 S. J. MACOUN ET AL.
situations to meet specific goals or demands (Lezak, 1995;
Miyake et al., 2000). Significant debate as to the structure
and nature of EF remains; however, Miyake et al. (2000)
helped to establish a “unity and diversity” model of EF that
is empirically supported and widely utilized, wherein the
construct is comprised of three underlying latent factors:
inhibition of prepotent responses, updating and monitoring
or working memory (WM), and shifting between mental
sets (often also referred to as cognitive flexibility).
Although metacognition and EF are conceptualized as
distinct constructs with unique contributions to cognition
and learning, contemporary theorists note strong links
between them (Roebers, 2017; Roebers et al., 2012; Roebers
& Feurer, 2016; Shimamura, 2008; Zelazo, 2015). At a cogni-
tive level, developing and engaging metacognition requires
slow and thoughtful reflection, which demands many core
subcomponents of attention and EF, including sustained
attention, inhibitory control, WM, and cognitive flexibility
(Roebers, 2017; Zelazo, 2015). Specifically, inhibitory control
is required to pause in order to reflect upon one’s thinking
(Kuhn & Pease, 2010), WM is needed to hold and manipu-
late reflections in mind while performing a task (Roebers,
2017), and cognitive flexibility is required to alternate
between focusing outwardly on the task and inwardly on
one’s own thought processes (Kuhn & Pease, 2010). Given
the link between EF and metacognition, it is not surprising
that children with attention/EF deficits struggle with meta-
cognition (Antshel et al., 2011; Tamm et al., 2014).
Given that metacognition is critical to the development
of self-directed learning, children with neurodevelopmental
disorders (NDD), who often experience deficits in metacog-
nition, are at a distinct disadvantage (Destan et al., 2014;
Roebers, 2017). For example, children with ADHD lag
behind typically developing peers in their ability to engage
in metacognitive monitoring (Antshel & Nastasi, 2008) and
often struggle to use metacognitive strategies without sup-
ports (Comoldi et al., 1999). Other studies have found that
children with Fetal Alcohol Spectrum Disorder (FASD) and
Autism Spectrum Disorder (ASD) use metacognitive strat-
egies less systematically and spontaneously than their typic-
ally developing peers (Bebko & Ricciuti, 2000; Loomes et al.,
2008). As such, remediation of these abilities has the poten-
tial to substantially improve outcomes and quality of life for
children with neurodevelopmental concerns.
The overlap between EF and metacognition would sug-
gest that interventions focusing on either construct could
lead to meaningful gains in the other, as well as in cogni-
tion, behavior, and learning. Research suggests that children
who participate in metacognitive training programs can
increase their knowledge and regulation of cognition
(Cornoldi et al., 2015; Makela et al., 2019; Sussan & Son,
2007; Tamm et al., 2014). Within educational contexts,
metacognitive training has been shown to improve key skills
in children between the ages of 4 and 6 years (Salmon et al.,
2011; Sussan & Son, 2007). Further, metacognitive instruc-
tion and practice could improve academic achievement in
school-age children, particularly when such instruction is
explicit and children are actively participating in their own
thinking processes (Ellis et al., 2012; Ellis et al., 2014).
Zelazo (2015) notes that improving metacognitive know-
ledge through scaffolded practice with reflection is likely the
most promising target for EF interventions. Metacognitive
reflection training has been shown to improve EF in typic-
ally developing children, as seen through gains in cognitive
flexibility and associated changes in brain regions that sup-
port conflict resolution (Espinet et al., 2013). In children
with ADHD, Tamm et al. (2014) demonstrated the positive
impact of a parent-delivered metacognitive training inter-
vention on cognitive measures of attention and EF (WM
attentional control) and day-to-day attention/EF behaviors.
Jonkman et al. (2016) demonstrated that 6 weeks of meta-
cognitive training led to gains on performance-based meas-
ures of memory, WM, and attention, as well as on parent
ratings of ADHD symptoms in school-age children with
ADHD. The authors concluded that the training-induced
increases in WM led to better top-down control of cognition
and behavior. Other positive effects of metacognitive train-
ing on cognition and behavior have been documented with
children and adults with brain injuries (Butler & Mulhern,
2005; Sohlberg & Mateer, 2001; Ylvisaker et al., 2007).
While metacognitive interventions have been traditionally
delivered in educational contexts, they are more recently being
included as key aspects of cognitive rehabilitation programs in
order to increase the generalizability of training effects
(Cicerone et al., 2011; Partanen et al., 2015; Schmiedek et al.,
2010). For example, Partanen et al. (2015) compared the effects
of computer-based WM training only to computer-based WM
training with metacognitive instruction in children with special
education needs. Results indicated significant gains in WM
performance in favor of the intervention that included a meta-
cognitive component, with transfer effects seen immediately
and at 6-month follow-up. The authors concluded that meta-
cognitive instruction optimizes the effects of computer-based
cognitive training. Makela et al. (2019) investigated the use of
metacognitive strategies in a game-based intervention
(Cognitive Carnival) designed to improve attention, WM, and
inhibition in children with FASD by targeting specific cognitive
processes (i.e. “process-specific training”; Pei et al., 2011).
Cognitive Carnival was delivered via an interventionist who
provided instruction and scaffolded support of metacognitive
strategies. The interventionist tracked the occurrence of both
prompted and spontaneous metacognitive strategies during
game play. Results indicated that the number of spontaneous
strategies used by children significantly increased over the
intervention in conjunction with a decrease in prompted strat-
egies (Makela et al., 2019). Makela et al. (2019) also observed
age-related trends, in that older children used more spontan-
eous and fewer prompted strategies than younger children.
Kerns et al. (2017) investigated a game-based intervention
called the Caribbean Quest (CQ) in children with ASD and
FASD. The CQ is a “serious game” (i.e. game with a thera-
peutic rather than purely entertainment purpose) that
employs a hierarchical and adaptive method to train atten-
tion, WM, and inhibition, using a validated neuroscientific
(process-specific) approach (Ehlhardt et al., 2008; Kleim &

Jones, 2008; Sohlberg et al., 2003). In line with recommen-
dations to combine process-specific and compensatory
approaches to maximize outcomes (Cicerone et al., 2011;
Kennedy et al., 2008; Partanen et al., 2015; Schmiedek et al.,
2010; Sohlberg et al., 2003), the CQ incorporates mass prac-
tice on cognitive exercises along with instruction in meta-
cognitive strategies. Kerns et al. (2017) preliminary results
indicated significant gains in attention, WM, and inhibition,
which generalized to reading skills. Exit interviews with
interventionists suggested that many children were applying
new metacognitive strategies to learning tasks within
the classroom.
To date, few metacognitive interventions designed specif-
ically for children exist, particularly those that can be deliv-
ered by paraprofessionals in naturalistic settings. Despite the
importance of metacognitive abilities in child development,
the research on metacognitive interventions in children with
neurodevelopmental concerns or those at risk of such diffi-
culties is very limited. The current study builds upon these
findings through the delivery of CQ to children with
teacher-identified attention, WM, and/or self-regulation defi-
cits. We hypothesized that CQ training would lead to gains
in children’s WM and metacognitive abilities. A range of
measures of metacognition were used, including perform-
ance measures, self-reports, and parent/Educational
Assistant (EA) ratings.
Methods
Participants
This study was part of a larger investigation of the feasibility
and potential benefits of the CQ in a mixed sample of chil-
dren presenting with deficits in attention/EF. The University
of Victoria Human Research Ethics Board approved this
research. Fifty children and their parents and 31 EAs were
recruited from 13 schools across three school districts in
British Columbia, Canada. Learning Support teachers at
schools identified children presenting with attention/EF
problems based on behavioral descriptors and guidelines
provided by the research team (see Appendix A, supplemen-
tary material). Learning Support teachers were chosen as the
primary contact for recruitment given that these school pro-
fessionals had the most awareness of the children who were
experiencing attention/EF challenges. Families who were
interested in participating completed a screening interview
prior to study enrollment to provide information related to
demographics, medical history, intervention history, atten-
tion/EF problems, and behavior/mental health. As part of
enrollment screening, parents completed the Swanson,
Nolan, and Pelham – IV (SNAP-IV) questionnaire (Swanson
et al., 1999). The SNAP-IV is a normed measure designed
to assess clinical symptoms of inattention and hyperactivity/
impulsivity in children with ADHD (Swanson et al., 1999).
Parents and teachers also completed an abbreviated version
of the Comprehensive Executive Function Inventory (CEFI;
Naglieri & Goldstein, 2013), a standardized questionnaire
designed to evaluate attention/EF in children ages 5 to
18 years. Four of the nine CEFI subscales thought to have
APPLIED NEUROPSYCHOLOGY: CHILD 3
the most relevance to the current intervention were adminis-
tered (attention, emotional regulation, self-monitoring,
and WM).
Initially, 83 families consented to participate in the study.
The study inclusion criteria was any child between ages 6
and 12 years presenting with attention and/or EF difficulties
as identified by their Learning Support teacher (see
Appendix A). As such the sample was not restricted to any
particular diagnoses and included a range of children both
with and without reported clinical diagnoses (e.g. ADHD,
ASD, etc., Table 1). Eight out of 50 children were reported
to have comorbid diagnoses (e.g. ADHD and Learning
Disorder, etc.). Children reported with ADHD received their
diagnoses prior to study entry by a qualified specialist (e.g.
Pediatrician, Psychiatrist or Psychologist) and those with
ASD had been diagnosed prior to study entry using B.C.
Standards and Guidelines for Autism diagnosis (Dua, 2003).
The B.C. Standards and Guidelines require administration of
the ADOS and ADI-R and a developmental cognitive/adap-
tive behavior assessment (Dua, 2003). Exclusion criteria
included children who were not able to communicate ver-
bally and those with moderate to severe intellectual disabil-
ities (ID; i.e. IQ <55), as it was deemed that these children
would not be able to meaningfully participate in the inter-
vention. It was decided ahead of time that children who did
not receive at least eight intervention hours would be
excluded on the basis that they would not have completed a
sufficient range and intensity of therapeutic activities to
meet the criteria for a process-specific intervention (Kleim
& Jones, 2008). Children were encouraged to continue with
other standard interventions that they were already receiving
at school and home, including learning assistance, counsel-
ing, speech-language therapy, and occupational therapy.
Design and procedures
Random assignment to an active intervention or waitlist
control group (i.e. to receive the intervention after study
completion) was conducted at the level of the school rather
than the child. This was done in order to avoid cross-
contamination of study groups via participating EAs using
intervention materials and metacognitive strategies with chil-
dren from the control group (Kazdin, 2017). At pretest,
blinded and trained Research Assistants (RAs) administered
an approximately two hour (including breaks) counterbal-
anced battery of outcome measures and an intellectual
screening measure. During pretesting, parents completed a
consent form and a behavioral questionnaire (CEFI- abbre-
viated version) and were given an abbreviated Teacher CEFI
to pass on to their child’s teacher. Immediately following the
intervention, all participants completed a 90-minute post-
test battery identical to the pretest battery, except that the
intelligence screening measure was not re-administered.
Parent rating scales were also re-administered at the post-
test appointment. Although teacher rating scales were
distributed by parents, low return rates precluded meaning-
ful analysis.
4 S. J. MACOUN ET AL.

Table 1. Participant pre-intervention data.

Intervention Control
Demographic variables N ¼ 19 N ¼ 31 p
Age in months (M [SD] 94.71 [19.65] 98.37 [18.29] .623
Gender (M/F) 20/1 21/9 .025
KBIT-2 SS FSIQ (M [SD] 98.86 [19.69] 81.23 [21.66] .939
Reported diagnosis (%) ADHD 43% 40% .842
ASD 25% 13% .344
Other 33% 20% .292
Interventions (%) LA 76% 60% .236
SLP 24% 17% .537
OT 29% 13% .184
Counseling 10% 23% .433
Total services (M [SD]) 1.43 [1.03] 1.13 [1.13] .347
Parent income (%) Below $25,000 3 2
$25,000–$49,999 4 8
$50,000–$100,000 12 14
Over $100,000 2 5
Ethnicity (%) Caucasian 76% 63% .340
Other 24% 37%
SNAP-IV I (M [SD]) 1.89 [0.69] 1.75 [0.49] .389
SNAP-IV H/I (M [SD]) 1.76 [0.81] 1.76 [0.73] .999
SNAP-IV C (M [SD]) 1.82 [0.66] 1.78 [0.72] .567
CEFI SS A–P (M [SD]) 80.8 [10.01] 82.67 [6.38] .424
CEFI SS ER–P (M [SD]) 77.00 [12.95] 85.76 [13.75] .030
CEFI SS SM P (M [SD]) 81.65 [11.48] 85.23[11.41] .283
CEFI SS WM–P (M [SD]) 78.70 [11.89] 82.83 [12.64] .252
CEFI SS A–T (M [SD]) 81.17 [9.45] 82.21 [11.31] .763
CEFI SS ER–T (M [SD]) 82.39 [13.91] 83.55 [12.75] .790
CEFI SS SM–T (M [SD]) 86.00 [8.45] 82.60 [8.98] .246
CEFI SS WM–T (M [SD]) 82.94 [13.52] 83.05 [11.87] .980
Note: ADHD: attention-deficit/hyperactivity disorder; ASD: autism spectrum disorder; Diagnosis other: learning disorder, anx-
iety disorder, mild intellectual disability, Tourette’s disorder, and oppositional defiant disorder; Ethnicity other: Aboriginal,
African American, East Asian, Asian, Hispanic; KBIT-2: Kaufman Brief Intelligence Test, Second Edition; SNAP-IV I: Inattention
subscale; SNAP-IV H/I: Hyperactivity/Impulsivity subscale; SNAP-IV C: Combined subscale; CEFI SS A: Attention subscale
standard score; ER: emotion regulation; SM: self-monitoring; WM: Working memory subscale; P: parent report;
T: teacher report.

The CQ was delivered in schools by trained EAs (i.e.
paraprofessional educators who work within schools to pro-
vide extra support for children who are having learning
and/or behavioral challenges). The EAs supported children
via the scaffolding of metacognitive strategies during game
play, which is a key aspect of the CQ intervention. Before
the intervention, EAs completed a structured, 5-hour web-
based training course that provided information on the
rationale of the intervention, how to support children
throughout the intervention, and provided systematic
instruction on teaching metacognitive strategies to children
(Kerns et al., 2017). This online training program was devel-
oped as a key aspect of the CQ game suite, is geared toward
paraprofessionals, and provides a manualized approach for
how to deliver the CQ intervention. The training is organ-
ized into a series of content modules and consists of
“mastery” quizzes, such that the trainee must complete
quizzes with 100% accuracy before being able to progress to
the next module. As part of their online training, EAs were
instructed on how to teach a range of general and specific
metacognitive strategies to children during CQ game play
(see Appendix B). They were also given scripts for teaching
metacognitive strategies with a focus on making the strat-
egies explicit and encouraging children to apply and reflect
on the strategies. To this end, EAs used a 5-step metacogni-
tive strategy script: (1) Identify the issue/difficulty; (2) State
the reason for the issue/difficulty; (3) Select and implement
a strategy; (4) Evaluate the outcome of the strategy; and (5)
Once a strategy works, celebrate success.
In the active intervention group, 14 EAs worked one-to-
one with 19 children such that some EAs were intervention-
ists for more than one child (10 EAs work with 1 child
only, and 4 EAs worked with more than 1 child). The inter-
vention was delivered in a 1:1 EA-child format over 6 to
8 weeks for a minimum of 8 hours. Intervention fidelity was
addressed by having EAs complete a series of quizzes associ-
ated with the training materials (100% accuracy required to
pass), two in-person RA visits with EAs during the training
sessions, and bi-weekly telephone calls between RAs and
EAs. EAs were also responsible for completing a record of
intervention progress during each training session (i.e. “CQ
Tracking Sheet”). On these tracking sheets, EAs recorded:
(1) date and session length; (2) training game, level, and
score; (3) type and outcome of metacognitive strategies
used; and (4) type of reward provided for that session (i.e.
none, tangible reward such as a small toy, social reward
such as engaging in a preferred activity or with a preferred
adult or peer, and/or verbal praise).
Caribbean Quest
The CQ is a therapeutic computer “game” designed to train
attention, inhibition, and WM in children ages six years and
older (Kerns et al., 2017). The CQ contains five games that
strengthen these cognitive abilities through massed practice
distributed over several weeks, with training evenly spaced
across the different games. All computer games are hierarch-
ical and adaptive (i.e. games are comprised of multiple levels

graded in difficulty and the difficulty within each level is
modified during game play based on an individual’s per-
formance). Between training tasks children are rewarded
with prizes (delivered by EAs) and bonus games (inherent
to the CQ) to enhance motivation.
Outcome measures
Attention and executive function
Working memory was assessed using a computerized ver-
sion of the Xylophone visual WM task (adapted from
McCarthy Scales of Children’s Abilities; McCarthy, 1970).
On a computer screen, children see and hear a mallet play-
ing a sequence of notes on a colorful xylophone. Children
repeat the sequence by using the mouse to select the same
series of notes. Each span length has two trials, with span
length increasing by one note as the child correctly performs
a trial. The task discontinues when both trials at a particular
span length are incorrect. The Xylophone WM task assesses
forward- (reproduce exact same sequence) and backward-
span lengths (sequence in reverse order). Daily attention/EF
abilities were assessed through parent ratings of attention/EF
using the abbreviated CEFI.
Metacognition: Junior Metacognitive Awareness
Inventory-Child (Jr. MAI-C)
The Jr. MAI-C is an adapted version of the Junior
Metacognitive Awareness Inventory, Version A (Jr. MAI:A;
Sperling et al., 2002). The Jr. MAI-A assesses metacognitive
awareness in children ages 7–10 years and includes 12 ques-
tions pertaining to metacognitive knowledge (i.e. declarative
metacognition) and regulation (procedural metacognition;
Brown, 1987). Validity analyses show high correlations of
the Jr. MAI-A with other inventories and the expected
developmental trends (Sperling et al., 2002). As many chil-
dren in the current study were younger than the age range
for the Jr. MAI-A, this measure was adapted to fit our
younger sample. Adaptations were based on developmental
literature regarding metacognition in younger children
(Roebers et al., 2014; Roebers & Spiess, 2017; Schneider,
2008; Veenman et al., 2006) and feedback from three fami-
lies with 5-year-olds who completed the Jr. MAI-A prior to
the study. First, the language in the questionnaire was sim-
plified, including altering mental state verbs (i.e. the word
“learn” was changed to “remember,” as this word is better
understood at a younger age). Second, the measure was
administered orally to eliminate reading demands. Third,
questions were changed from first- to the second-person.
Fourth, examples were added to make questions more con-
crete and contextualized. Fifth, question seven from the ori-
ginal measure was removed because it was deemed too
abstract. Finally, instead of a three-point Likert-type fill in
the dot scale, children used a six-point thermometer-style
scale with a movable red bar. At the bottom of the scale
(representing “never”) there was a picture of a cartoon child
holding no balloons. In the middle of the scale (representing
“sometimes”) the cartoon child was holding one balloon and
APPLIED NEUROPSYCHOLOGY: CHILD 5
at the top of the scale (representing “always”) the cartoon
child was holding seven balloons.
The Metacognitive Strategy Use Questionnaire (MSUQ)
The MSUQ consists of four open-ended questions where
children were asked to list as many strategies as possible to
help another hypothetical child who is struggling with: (1)
remembering, (2) paying attention, (3) regulating his emo-
tions, and (4) sitting still. Each response was scored using a
4-point rating scale developed by the authors (adapted from
Whitebread et al., 2009), based on the presence or absence
of specific metacognitive indicators. Scores ranged from 0
(no answer or irrelevant) to 3 (highly metacognitive answer).
To receive a 3 point score, the answer needed to include
both a strategy and a description of why that strategy is use-
ful (Annevirta & Vauras, 2001). A 2-point score reflected
answers that described a specific strategy without indicating
why it is useful, whereas a 1-point score reflected answers
that offered nonspecific or vague strategies. Three raters
applied the above noted coding scheme to a random sample
of 10 participants, yielding high interclass correlations (ICC
(2,3)¼0.86, <p.001). The MSUQ captures aspects of both
declarative and procedural metacognition.
Xylophone self-monitoring probe
To provide an objective behavioral measure of procedural
metacognition (metacognitive monitoring), a self-monitoring
probe was embedded within the Xylophone WM task.
Immediately following each response, children indicated
whether they believed that they had correctly repeated the
sequence or not.
Xylophone post-error slowing
Utilizing the traditional method for quantifying post-error
slowing (Dutilh et al., 2012), we compared the difference in
mean reaction time for each participant on trials that fol-
lowed an error versus trials that followed a correct response.
Data was screened and implausible outliers were removed
including extremely fast responses (150 ms or less) or
extremely slow responses (calculated for each participant as
three standard deviations outside of their respective
mean RTs).
Junior Metacognitive Awareness Inventory-Parent Version
(Jr. MAI-P) and Jr. Metacognitive Awareness Inventory-
Educational Assistant Version (Jr. MAI-E)
Parents and EAs were administered the adapted Jr. MAI-C
to assess their perception of the child’s metacognition.
Parents completed the Jr. MAI-P questionnaire in-person at
the time of the child’s pre- and post-testing, whereas EAs
(Jr. MAI-E) were e-mailed a link to the questionnaire to be
completed through an online survey host.
6 S. J. MACOUN ET AL.

Table 2. Means and standard deviations as a function of group (intervention vs. control) and intervention (pre vs. post intervention).
Intervention group Control group
Pre-intervention Post-intervention Pre-intervention Post-intervention
Test M SD M SD M SD M SD
Xylophone WM 7.65 3.9 9.12 3.59 8.3 2.97 7.87 2.79
CEFI-P ER 78 12.65 87.39 14.04 83.83 13.14 88.03 11.32
Jr. MAI-P 3.26 0.35 3.86 0.49 3.44 0.6 3.68 0.58
CEFI-P SM 82.33 10.31 90.67 9.47 84.53 11.64 85.87 11.57
Xylophone SM 8.11 4.76 10.05 4.72 9.38 3.2 9.29 3.1
Xylophone PES 170.36 744.05 719.16 884.22 181.23 516.75 123.6 393.64
Jr. MAI-P (<7 yrs) 3.26 0.35 3.86 0.49 3.49 0.62 3.7 0.44
MSUQ (ASD/ADHD) 4.75 4.16 6.42 5.04 4.92 3.07 4.92 3.48
Note: Xylophone WM: Xylophone WM task; CEFI-P ER: Comprehensive Executive Function Inventory Parent Emotional Regulation scale; Jr. MAI-P: Jr.
Metacognitive Inventory Parent; CEFI-P SM: Comprehensive Executive Function Inventory Self Monitoring scale; Xylophone SM: Xylophone Self Monitoring
Probe; Xylophone PES: Xylophone Post Error Slowing; Jr. MAI-P under 7: Jr. MAI-P for children ages 7 years and under; MUSQ (ASD/ADHD): Metacognitive
Strategy Use Questionnaire for children with ASD/ADHD only.

Tracking booklet data (M ¼ 11.67, SD ¼ 1.69, range 8–16). Ninety-five percent of

Daily tracking sheets were completed by the EAs during
each CQ training session and were submitted to the research
team at the end of the intervention. EAs recorded the spe-
cific metacognitive strategies taught/used by children,
including whether strategies were provided or prompted by
the interventionist or generated spontaneously by the child.
This data was also used to assess intervention fidelity.
Results
All analyses were performed using SPSS 24.0.
Final sample
EAs submitted fully completed tracking booklets, defined as
submitting completed tracking sheets for at least 90% of
their sessions with the child. A review of tracking sheets
indicated that EAs followed training guidelines for session
duration (approximately 30 minutes recommended;
M ¼ 29.39, SD ¼ 2.35), number of games per session
(between 2 and 4 recommended; M ¼ 3.7, SD ¼ 0.88), and
range of metacognitive strategies taught per child (of a total
of 10 strategies, Mode ¼ 8; M ¼ 5.5, SD ¼ 2.84). Further, a
review of tracking sheets indicated that the metacognitive
strategies used were appropriate for the specific games as
per CQ training site instructions (e.g. use of a rehearsal
strategy for memory tasks, etc.).

Thirty-three children were excluded from the original sam-

ple due to incompatible child-EA schedules such that they
did not start the intervention (9), insufficient intervention
hours (<8 hours, range 0–7) (5), missing data on pre- and/
or post-testing (18), and moderate intellectual disability (1).
The final sample for analysis included 50 children (41 males,
9 females, Mage 7.64 years, SD 1.55, range 5–10 years). The
sample was predominantly male, middle class and
Caucasian. Both the intervention and waitlist control groups
had intellectual ability in the normal range (Kaufman Brief
Intelligence Test Second Edition; KBIT-2; Kaufman &
Kaufman, 2004). Mean values on the parent-completed
SNAP-IV revealed that both groups exceeded clinical cutoffs
on ADHD subscales for hyperactivity, inattentiveness, and
combined presentations (scores within the top 5%). Scores
for both groups on the CEFI exceeded clinical cutoff points
in all domains assessed (i.e. attention, emotional regulation,
self-monitoring, and WM) for both parent and teacher rat-
ings. With the exception of gender, the intervention and
control groups did not differ significantly on demographics,
preexisting attention/EF problems, use of other interven-
tions, diagnostic status, number of comorbidities, or intellec-
tual ability (Table 1).
Fidelity
Eight-five percent of EA-child pairs who started the inter-
vention completed a minimum of 8 hours of CQ training
Analysis overview
Pre/post-test changes in EF and metacognition were exam-
ined using 2 (control vs. active intervention group) by 2
(pre to post intervention testing) repeated measures
ANOVAs and g2 was calculated to determine effect size.
Statistical assumptions were met, there were no outliers, and
the data was normally distributed at each time point, as
assessed by boxplot and Shapiro-Wilk test (p >.05), respect-
ively. The CQ intervention and control groups did not sig-
nificantly differ at pretest on any of the outcome variables.
Significant interactions were followed up with paired sam-
ples t-tests run on the control and active intervention
groups with a Bonferroni adjusted alpha level of 0.025 per
comparison (0.05/2; Howell, 2002). Due to technical chal-
lenges and rating scale return rates, 3 cases were excluded
from the Xylophone WM test (1 pre-/2 post-test), 9 cases
from the Xylophone post error slowing task, 5 cases from
the MSUQ (1 pre-/4 post-test), 1 case from the Jr. MAI-C
(1 post-test), 4 cases from the Jr. MAI-P (2 pretest/2 post-
test), and 13 cases from the CEFI-P (2 pre-/11 post-test).
Post intervention return rates from the Jr. MAI-E and
teacher CEFI-T were too low for meaningful analyses. Table
2 provides means and standard deviations for the analyses
reported below.
 APPLIED NEUROPSYCHOLOGY: CHILD 7

Assessed for eligibility (n = 83)

Enrolment
Excluded (n = 1)
Child was nonverbal (1)
Randomized (n = 73) Incompable EA/Child schedules (9)
Randomizaon occurred at the
level of the school
Intervenon and
Pre-post tesng

Intervenon group (n = 35) Control group (n = 38)

<8 training hours (5)

Missed/incomplete pre-test (2) Missed/incomplete pre-test (0)

Missed/incomplete post-test (9) Missed/incomplete post-test (7)

Analyzed (n = 19) Analyzed (n = 31)

Analysis

Figure 1. Recruitment flow chart.

Working Memory (Xylophone Task) Metacognition. Data analysis comparing pre to post test
9.5
changes across the entire sample showed variable outcomes
on metacognitive measures. On performance measures of
Est. Marginal Means

metacognition, a significant group by pre/post-test inter-

9
8.5
8 intervention group (t(18) ¼ -2.53, p < .025, d ¼ 0.60) but no
7.5
Pre
Intervenon Group
Figure 2. WM (Xylophone WM) outcomes from pre- to post-test.
Benefits
Attention/EF
On the Xylophone WM task there was a statistically signifi-
cant interaction between group and pre/post-test (F(1,
45) ¼ 7.15, p<.05, g2 ¼ 0.14; see Figure 2). Follow-up with
paired samples t-tests, with Bonferroni adjustment, showed
that the CQ intervention group trended toward significant
gains in WM (t(16) ¼ 2.29, p ¼ .03, d ¼ 0.20) whereas the
control group did not (t(29) ¼ 1.10, p ¼ .28).
There were no significant group by pre/post-test interac-
tions seen for parent ratings on CEFI-P attention or WM
subscales. However, follow-up paired samples t-tests, with
Bonferroni adjustment, indicated a non-significant trend
toward gains on the CEFI-P in emotional regulation from
pre- to post-test within the CQ intervention group (F(1,
46) ¼ 2.68, p ¼ .11; see Figure 3). Low return rates for the
post-test teacher CEFI-T precluded meaningful pre/post-
test analyses.
action was seen for the Xylophone self-monitoring probe
(F(1,48) ¼ 5.59, p<.05, g2 ¼ 0.10; see Figure 4). Follow-up
paired sample t-tests, with Bonferroni adjustment, indicated
significant gains in self-monitoring accuracy for the CQ
significant findings in the control group
(t(30) ¼ 0.20, p ¼ .85).
Post When post-error slowing was calculated on reaction
Control Group times for the Xylophone task, there was a significant group
by pre/post-test interaction (F(1,39) ¼ 4.56 p<.05, g2 ¼ 0.11;
see Figure 5). Follow-up paired samples t-tests, with
Bonferroni adjustment, indicated a trend toward gains from
pre- to post-test in the CQ intervention group only
(t(18) ¼ 1.98, p ¼ .06).
Low post-intervention return rates precluded analysis of
the EA completed Jr. MAI-E. On the Jr. MAI-C, Jr.MAI-P,
and MSUQ there were no group by pre/post-test
interactions within the overall sample. However, a statistic-
ally significant interaction was seen between group and pre/
post-test on the CEFI-P self-monitoring subscale
(F(1,46) ¼ 7.08, p ¼ .01, g2 ¼ 0.13). Follow-up paired sample
t-tests, with Bonferroni adjustment, indicated a significant
gain in the CQ intervention group (t(17) ¼ 3.49, p<.01,
d ¼ 0.82), but not the control group (t(30) ¼ 0.92, p ¼ .37;
see Figure 6).
Given differences in EF and metacognition in younger
and older children (Roebers et al., 2009; Roebers & Spiess,
2017; Semrud-Clikeman & Ellison, 2009), to evaluate
whether the intervention impacted younger and older
8 S. J. MACOUN ET AL.

Emoon Regulaon (CEFI-Parent) Post-Error Slowing - WM Task

90
(Xylophone)

Est. Marginal Means (ms)

800
88
Est. Marginal Means

700
86
600
84 500
82 400
300
80
200
78
100
76 0
Pre Post Pre Post
Intervenon Group Control Group
Figure 3. Parent reported Emotional Regulation (CEFI-P) outcomes from pre- to Intervenon Group Control Group
post-test.
Figure 5. Post-error slowing (Xylophone post error slowing) from pre to
post test.

Self-Monitoring (Xylophone Task)

Self-Monitoring - Parent Rangs
10.5
(CEFI-P)
92
Est. Marginal Means

10

Est. Marginal Means

9.5
9
8.5
8
Pre
Intervenon Group
Figure 4. Performance self monitoring (Xylophone self monitoring probe) out-
comes from pre- to post-test.
children differently, these analyses were run separately for
children ages 7 years and younger and those older than age
7 years. For children older than age 7 years there were no
significant interactions found between group and pre-post
test for the Jr. MAI-C Jr. MAI-P or MSUQ. However, for
children under age 7 years, the interaction between group
and pre-post test on the Jr. MAI-P trended toward, but
failed to reach, significance (F(1,23) ¼ 3.4, p ¼ .07; Figure 7).
Analyses were additionally run separately for children
with and without a reported NDD (ADHD/ASD), due to
documented differences in EF and metacognition in children
with ASD/ADHD (Antshel & Nastasi, 2008; Bebko &
Ricciuti, 2000). There were no significant group by pre/post-
test interactions for the JMAI-P, Jr. MAI-C or MSUQ for
children with or without a diagnosed NDD. For children in
the NDD group there were non-significant trends toward
gains on the MSUQ (F(1,25) ¼ 3.6, p ¼ .13; Figure 8).
Feasibility and acceptability
Exit interviews following study completion were conducted
with EAs who delivered the intervention, in addition to their
school administrators. Fifty-seven percent of EAs reported
that the CQ was not disruptive during the school day
whereas 43% reported that it was minorly disruptive to the
child (23%), classroom (9%), or mildly disruptive for other
90
88
86
84
Post 82
Pre Post
Control Group
Intervenon Group Control Group
Figure 6. Parent reported self-monitoring (CEFI-P) outcomes from pre- to
post-test.
(nonspecified) reasons (11%). Seventy-eight percent of EAs
reported that the intervention was not difficult or only occa-
sionally difficult to schedule. Educational Assistants reported
anecdotally that there were improvements in EA-child rela-
tionships as a result of completing the intervention together.
Further, 67% of EAs reported gains in their own knowledge
as a result of doing the training/intervention and that skills/
knowledge gained from delivering the intervention would
benefit their future practice (97%). The primary barriers
reported in schools pertained to ease of scheduling, com-
puter access, access to a quiet setting, and missed instruc-
tional time, although administrators reported that they
believed the benefits to the schools, children, and EAs out-
weighed these challenges.
Discussion
The results of this randomized feasibility trial for CQ, a
game-based attention and EF intervention, provides prelim-
inary support for CQs potential to improve aspects of EF
and metacognition in children. Pre/post intervention com-
parisons indicated gains in aspects of attention, EF, and
metacognition. Significant gains were seen on a perform-
ance-based measure of visual WM, although this was not
reflected in parent ratings of WM. Gains were also seen in

Metacognive Awareness - Parent
Rangs (JrMAI-P)
4 pleted metacognitive inventory (Jr. MAI-E), suggesting that
Est. Marginal Means
3.8
3.6
3.4
3.2
Pre Post
Intervenon Group Control Group
Figure 7. Parent reported metacognition (Jr.MAI-P) outcomes from pre- to
post-test.
Metacognive Strategy Use
Self-Report (MSUQ)
7 type of collateral informant within our sample. Finally, par-
Est. Marginal Means
6.5
6
5.5
5 and something different than EF.
4.5
Pre Post
Intervenon Group Control Group
Figure 8. Child metacognitive strategy self report (MSUQ) outcomes from pre-
to post-test.
parent ratings of self-monitoring. Parent ratings of attention
did not change from pre- to post-intervention. Teacher rat-
ings could not be meaningfully analyzed due to low ques-
tionnaire return rates. Following recommendations in the
literature, we attempted to mitigate challenges in assessing
metacognition through the use of multiple performance
measures and raters (i.e. parent, EA, and child via Jr. MAI-
P/-E/-C) to evaluate children’s understanding and use of
metacognitive strategies in various contexts (Marulis et al.,
2016). Furthermore, we administered a child interview
(MSUQ) to assess metacognitive awareness (i.e. listing meta-
cognitive strategies) and regulation (i.e. knowing when and
how such strategies might be helpful).
Interestingly, pretest parent, EA, and child ratings on the
metacognitive awareness questionnaires were not signifi-
cantly related, failing to replicate previous studies reporting
a positive correlation between parent and EA reports and a
negative correlation between parent/EA reports and child
self-reports (Fernandez-duque et al., 2000; Leary & Sloutsky,
2017; Loon et al., 2017; Sperling et al., 2002). This could be
due to a lack of sensitivity of these tools in our sample of
young children, in which these measures have not been
properly validated. Alternatively, it may be that these meas-
ures are capturing different aspects of metacognitive aware-
ness based on the respondent’s perspectives and settings.
There are several points that support this possibility. First,
APPLIED NEUROPSYCHOLOGY: CHILD 9
in the current study, intellectual ability was only correlated
with one of six measures of metacognition, the EA-com-
EAs could be more likely to observe children in cognitively
demanding situations where there is greater overlap between
intellectual and metacognitive ability (Arffa, 2007; Benedek
et al., 2014). The lack of correlation between intellectual
ability and the five other measures of metacognition suggests
that most of our metacognitive measures were tapping into
something other than intellectual ability. This is consistent
with literature suggesting that, even though metacognition
and intellectual ability are used in cognitively demanding
situations, they are distinct constructs (Roebers et al., 2012;
Tsalas et al., 2017). Second, while there is an association
between EF and metacognition (Roebers & Spiess, 2017;
Shimamura, 2008; Zelazo, 2015), the strength of this rela-
tionship differed across metacognitive measures and/or the
ent ratings on the CEFI-P for attention, emotional regula-
tion, self-monitoring, and WM were significantly related to
their own ratings on the Jr. MAI-P, but not to teacher/EA
ratings or performance measures of metacognition. These
results suggest that the metacognitive measures employed in
this study were tapping different aspects of metacognition
Post-intervention changes with respect to metacognitive
awareness were variable depending upon the respondent and
the measure. No significant gains were seen on child self-
reports of metacognitive awareness (i.e. tapping child metacog-
nitive knowledge/understanding of their own cognition) or
regulation (i.e. tapping child metacognitive strategy proficiency
via their listing of relevant strategies for a given scenario).
Children’s ability to list metacognitive strategies and describe
their use in specific contexts did not significantly change from
pre- to post-intervention for the overall sample. However,
when the sample was split into children with reported diagno-
ses of ASD and/or ADHD versus those without, children with
these diagnoses potentially demonstrated some relative gains in
their ability to list and describe metacognitive strategies. This
preliminary finding is interesting given research showing that
children with ASD and/or ADHD have lower metacognitive
ability than their peers and tend to use metacognitive strategies
less spontaneously and systematically without such intervention
supports (Antshel & Nastasi, 2008; Bebko & Ricciuti, 2000;
Loomes et al., 2008). As metacognition is key for regulating
cognition and learning, these children are at a distinct disad-
vantage that places them at increased risk for learning difficul-
ties (Antshel & Nastasi, 2008). These results are also consistent
with previous research that has demonstrated that explicit
teaching of metacognitive strategies can increase metacognitive
abilities in children with already low abilities in this area
(Cross & Paris, 1988; Schraw & Moshman, 1995). The poten-
tial of the CQ to improve these abilities is clinically important,
given the association between metacognitive knowledge/aware-
ness, application of metacognitive skills, and cognitive/learning
outcomes (Destan et al., 2017; Leary & Sloutsky, 2017; Oguz &
Sahin, 2011; Roebers, 2017; Roebers & Spiess, 2017).
10 S. J. MACOUN ET AL.
A self-monitoring probe and measure of post-error slow-
ing were utilized to assess metacognitive monitoring and
control, which are both aspects of metacognitive regulation.
Children who participated in the CQ showed significant
gains on a measure of metacognitive self-monitoring, which
corresponded to similar gains in parent pre-post interven-
tion ratings of their child’s self-monitoring abilities in day-
to-day activities, providing preliminary evidence for far
transfer of treatment-related gains. These gains may be due
to explicit instruction in self-monitoring strategies, which
were taught to children by EAs as part of the CQ. However,
improved self-monitoring could also be related to gains in
WM due to the process-specific aspect of this intervention
(i.e., with instruction, process-specific training, or both,
impacting gains). Specifically, research suggests that
although WM and metacognitive regulation are distinct con-
structs they are strongly associated because monitoring and
controlling cognition requires the integration of new and
existing information via online maintenance and manipula-
tion of information (Roebers, 2017; Shimamura, 2008).
WM was also significantly associated with child reports
of metacognitive strategy use, which we conceptualize as
having both declarative (knowledge) and procedural (regula-
tion) components. We also found a significant association
between WM and metacognitive monitoring both pre- and
post–intervention. Interestingly, WM was not significantly
associated with metacognitive knowledge based on parent,
EA or child self-reports, supporting research findings of a
stronger link between WM and procedural metacognition
than WM and declarative metacognition (Leary & Sloutsky,
2017; Roebers & Feurer, 2016; Roebers & Spiess, 2017).
Further, WM was not associated with metacognitive control
as measured through post-error slowing, which is in contrast
to some research that has shown a stronger link between
WM and metacognitive control than monitoring (Roebers,
2017; Roebers & Feurer, 2016).
Finally, results indicate that the CQ can be delivered with
fidelity by paraprofessionals (e.g. EAs) in school settings, mak-
ing it accessible and feasible for a broad range of children.
After the attrition that occurred at the very beginning of the
study (primarily due to EA-child scheduling conflicts), the
majority of EA-child pairs (85%) completed the required
intervention hours without difficulty during the school day,
across a range of school contexts. EAs completed online train-
ing in no more than 5-hours and delivered both the game-
based and metacognitive aspects of this intervention as
directed. Exit interviews indicated that all children enjoyed the
intervention and that EAs felt that the CQ was not disruptive
or difficult to deliver in their schools. The process of deliver-
ing the intervention led to EA reported gains in EA/child rela-
tions, as well as gains in EA knowledge and skills. CQ was
perceived by administrators as a viable and beneficial interven-
tion option within their school settings.
Limitations
The current study has several limitations that should be
taken into account in future studies. The first limitation
pertains to our measures, although it is not exclusive to our
study. There are limited measures of metacognitive ability,
especially for young children. Indeed, the Jr. MAI-C is not
validated in children under the age of 7 years. As the present
study included children under age 7, including those with
neurodevelopmental disorders who may function closer to
younger developmental ages and who are known to have
limited metacognitive ability (Antshel & Nastasi, 2008), the
validity of this measure in our sample is questionable.
Future studies should include measures specifically designed
for young children and observational measures of children’s
actual metacognitive strategy use within naturalistic contexts.
Although, in the current study, children with reported
ADHD and/or ASD made potential gains in strategy nam-
ing, it is unclear whether these gains transferred into the
classroom. As the goal for any intervention is to effect last-
ing real world change, longitudinal studies that incorporate
measures to assess both near and far transfer of skills are
required to determine the true efficacy of the CQ.
A second limitation pertains to our sample. As there
were limited diagnostic exclusions, this sample was com-
prised of children with a wide range of abilities and diagno-
ses. This was done intentionally, to permit a range of
children to participate in a potentially helpful cognitive
intervention and to capture the more ecologically valid
diversity of children with attention, EF, and metacognitive
problems. However, as a result, we are not able to comment
on the potential benefits of the CQ as it pertains to children
with specific clinical diagnoses, other than that aspects of
the intervention may have been be more beneficial for chil-
dren with reported neurodevelopmental disorders (ADHD/
ASD) than without. Future investigations of the CQ with
larger samples that target specific clinical diagnoses and a
broader age range would be helpful. In addition, any non-
significant trends that were reported are based on small
sample sizes and are therefore difficult to interpret, requir-
ing larger samples and replication in future studies to be
validated. The sample was further limited by the high pro-
portion of boys who were enrolled in the study as a result
of our recruitment procedures and recruitment sampling by
school rather than by individual child (Kazdin, 2017). That
being said, this type of sampling approach is not particularly
unusual in school-based research and the sample does accur-
ately reflect the types of children who are presenting with
more obvious attention/EF challenges in schools.
A third limitation pertains to our use of a waitlist-control
design, which meant that study participants were not blind
to intervention status. This clearly raises the possibility of
bias and halo effects and, therefore, randomized controlled
trials of the CQ that include longitudinal follow-up are
clearly needed. Further, within this study, we chose to
exclude children with under 8 hours of intervention, which
is in contrast to recent intention to treat (ITT) recommen-
dations (Gupta, 2011). Future studies with a larger sample
size should investigate outcomes in children who did not
complete the requisite intervention hours. Finally longitu-
dinal follow-up that incorporates a wider range of outcome

measures, including academic achievement tasks, will be
important in assessing maintenance and transfer of gains.
Conclusion
Finally, the CQ is a combined intervention that includes
both process-specific and compensatory aspects. On the one
hand, this is a strength of the CQ as it follows recommenda-
tions to combine WM training with metacognitive instruc-
tion and sets the CQ apart from other similar interventions
(Cicerone et al., 2011; Jonkman et al., 2016; Partanen et al.,
2015; Sohlberg et al., 2003). While we believe that both
aspects of the intervention are critical, it is not possible to
establish whether gains were due to metacognitive instruc-
tion, process-specific training, or a combination of the two.
We recommend future studies that compare outcomes from
each component of the CQ intervention individually and
together. EF and metacognitive abilities are crucial for suc-
cess academically and behaviorally, but these abilities are
commonly impaired in children with neurodevelopmental
disorders. The current findings provide preliminary support
for the CQ as a potentially useful intervention for improving
EF and metacognition in children. Future research is neces-
sary to assess the efficacy of this intervention on both prox-
imal and distal outcomes, in addition to its applicability
within particular clinical samples.
Ethical approval
This research was conducted with the approval of the
University Human Ethics Board and in accordance with Tri-
Council Human Ethics guidelines.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
This work was supported by Kids Brain Health Network.
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