Abstract

An aspect of metacognition, metamemory (knowledge and awareness of one's memory) was

investigated across time in preschool children with ADHD (n = 31) and a sample of age, sex,
socioeconomic and IQ-matched typically developing children (n = 31). Only children with stable ADHD
diagnoses were included. Participants were assessed on a variety of cognitive and parent report
measures. Longitudinal results indicated that the preschool children with ADHD and typically
developing children had similar intellectual capacities. In addition, at age 4, children with ADHD and
typically developing children had comparable metamemory skills. Nevertheless, one year later, when
control participants made strong gains in metamemory development, children with ADHD began to lag
behind. It is therefore crucial that metamemory difficulties in children with ADHD are detected as soon
as they appear so that they can be fully assessed and remediation programs put in place in the school
and home.

Early Childhood Metamemory Development With ADHD

Introduction

Metacognition, or the knowledge, awareness, and control of cognitive processes, is a topic of

considerable interest in developmental psychology ([Bjorklund, 1987] and [Kreutzer et al., 1975]).
Aspects of metacognition that have been researched most heavily are metamemory and
metacomprehension; metamemory refers to accuracy in predicting memory performance, knowledge
about memory strategies and how best to regulate study strategies (Cavanaugh & Perlmutter, 1982).
Metacomprehension refers to thoughts about comprehension and like metamemory, is often quantified
as a rate of accuracy in predicting performance. Metamemory is easier to assess in young children, as
metacomprehension experiments often rely on reading passages and answering questions ([Matlin,
2005] and [Nelson, 1999]).

Using a cohort sequential design, the classic study by Yussen and Levy (1975) demonstrated
developmental progression of metamemory through childhood and adolescence. When asked to state
how many words they could hold in their memory, preschoolers ( age 4.6 years) vastly overestimated
the number of items they could recall. Nonetheless, by age 8 (3rd grade), performance on this task was
very similar to college students and very close to actual memory performance. This suggests that
between the ages of 4 and 8, impressive improvements in metamemory occur.

Others have considered how best to explain the stark improvements in metamemory between ages 4
and 8 (Schneider & Sodian, 1988). Some have proposed that the improvement in metamemory parallels
the development of theory of mind; as children expand their knowledge about how their mind works
and come to understand that others have minds as well, their metamemory skills improve ([Flavell et al.,
2000] and [Schneider, 1999]). Others have suggested that based on an association between
metamemory and actual memory performance, the use of strategies improves metamemory that, in
turn, affects memory performance ([Schneider and Pressley, 1997] and [Schneider, 1999]). In addition,
younger children often do not realize that effort must be exerted in order to memorize material and that
memory strategies are not spontaneously used (Flavell, Miller, & Miller, 2002). Improvements in impulse
regulation also may account for the expansion of metamemory skills, as metamemory is more accurate
when waiting before making recall predictions (Dunlosky & Nelson, 1994). In sum, metamemory
development is most likely multifactorial.

Research questions

This study will analyse the following questions:

How Metamemory development in preschool children with ADHD will overcome?

Research aims

The aim of this research study is to analyse the Metamemory development in preschool children
with ADHD. Because the process of metamemory may begin in preschool, the ontogenic course of
metamemory development is rather protracted. For example, by age 3, children recognize that they
will remember a smaller set of pictures better than a larger set (Schneider & Pressley, 1997).
Nevertheless, preschool children generally do not comprehend that effort must be exerted in order to
memorize (Joyner & Kurtz-Costes, 1997). Similarly, 7-year olds are often unaware that words are easier
to remember when the words are related, rather than randomly selected (Schneider & Pressley, 1997).
Likewise, older children ( ages 8–9) are often inaccurate or poor at determining whether or not they
have committed some piece of information to memory (Schneider, 1999).

Research paradigm

Metacognition and metamemory are often subsumed under the umbrella construct, “executive
function” (Cornoldi, Barbieri, Gaiani, & Zocchi, 1999). Executive function is a rather ambiguous term that
refers to a set of various interrelated cognitive abilities that operate metaphorically as a company
“executive” and organize the brain's mental resources to accomplish pre-specified goals ([Denckla,
1989] and [Goldman-Rakic, 1987]). Executive functioning can be affected by various medical and
psychiatric disorders (Pennington & Ozonoff, 1996) including attention-deficit/hyperactivity disorder
(ADHD; Barkley, 1997). There is a burgeoning interest in executive functioning in preschool children
([Hughes, 2002] and [Isquith et al., 2005]) and it is somewhat surprising that few extant data have
specifically addressed executive functioning in preschool children with ADHD.
Research Method

In this study we used both quantitative and qualitative research methods.

Qualitative Research Methods

In qualitative research methods we will analyse different journals and research database. Like A
few investigators have empirically addressed metamemory development in children with ADHD. For
example, Cornoldi et al. (1999) studied 6th and 8th grade children with ADHD and controls using a
variety of measures designed to tap into the core deficits (e.g., impulse control) of children with ADHD.
Also included in the research protocol was a metamemory questionnaire. Their data demonstrated that
relative to control participants, middle school children with ADHD had less efficient and organized
memory strategies yet improved appreciably when provided metacognitive assistance (Cornoldi et al.,
1999). The control children did not improve much with metacognitive support, suggesting that they had
already developed the necessary abilities to perform the task (Cornoldi et al., 1999).

Voelker, Carter, Sprague, Gdowski, and Lachar (1989) also investigated metamemory in ADHD. These
researchers compared twelve boys with ADHD ( ages 6–12) on a list-learning task of semantically
related words. In addition, children completed a metamemory questionnaire designed to assess their
knowledge of how different situations may affect encoding and retrieval. Boys with ADHD performed
comparably to control participants on metamemory knowledge and less complex list learning. However,
when effortful strategic deployment (e.g., semantic clustering) was required, boys with ADHD performed
less well than control participants. This suggested a utilization, not knowledge, deficiency.

Given the developmental psychology literature documenting impressive improvements in metamemory

between ages 4 and 8, we were interested in researching whether a similar developmental trajectory
occurs in children with ADHD. In light of the high rates of learning disabilities and academic
underachievement in children with ADHD ([Frick et al., 1991], [Hinshaw, 1992] and [Willcutt et al.,
2005]) as well as the benefits of early identification and intervention for children with learning
disabilities (O'Connor, Harty, & Fulmer, 2005), we feel that this is an important and potentially valuable
area of research.

Similarly, due to the lack of data on preschool children with ADHD, early intervention planning for ADHD
currently relies largely on data from children of school- age; in order to possibly better inform
appropriate preventive and intervention efforts, more information is needed on the “start point(s)” or
subcomponents (e.g., metamemory) of cognitive difficulties rather than focusing on the “end” points
(e.g., memory recall). The current project represents an initial longitudinal investigation into
metamemory development in preschool children with ADHD. At age 4, metacognition and
metamemory is still an emerging skill. However, by age 5, metamemory has begun its ontogenic
course. Accordingly, we hypothesized that at age 4, no differences would exist between control
participants and participants with ADHD. However, at age 5, differences on metamemory measures
would exist between the two groups.
ADHD is difficult to diagnose in children younger than age 4 or 5 years, mainly due to variable behaviors
that may be similar to characteristic symptoms. Additionally, it is difficult to diagnose a preschool child
because symptoms of inattention are not often readily observed since young children typically
experience few demands for sustained attention (APA, 1994). Not surprisingly, the diagnosis of ADHD in
preschoolers has been a topic of debate ([Barkley, 1997], [Byrne et al., 1998], [Campbell et al., 1982],
[DeWolfe et al., 2000], [Shelton et al., 2000] and [Sonuga-Barke et al., 2005]). For example, while
longitudinal data suggest that preschool children with high levels of activity and impulsivity continue to
display comparable hyperactive and impulsive behaviors in childhood ([Byrne et al., 1998] and
[Campbell et al., 1994]), other data indicate that not all children with early ADHD symptoms continue to
have difficulties, and some children do not develop ADHD symptoms (inattention) until middle childhood
(Campbell, 1995). Nonetheless, the general consensus from these data is that ADHD can be reliably
diagnosed in preschool children ([Applegate et al., 1997] and [Lahey et al., 1998]) with adequate
predictive validity into childhood (Root & Resnick, 2003).

Quantitative Research Methods

Participants

Our longitudinal study population consisted of two groups based on the presence of ADHD. Participating
families were selected from consecutive referrals to a general child and adolescent outpatient
psychiatry clinic over a 4-year period. All of the participating children were 4 years old at the time of
referral. Although we originally had 88 children who were referred to our study for having “disruptive
behavior”, “overactivity” and/or “hyperactivity”, many families (n = 27) did not express interest in
participating. In addition, of those who did express interest, two failed to keep the evaluation
appointment and seven other children did not meet the diagnostic threshold for ADHD. Children who
were in foster-care (n = 13) at the time of referral were excluded from participation. Finally, eight of our
participants who met diagnostic criteria for ADHD at Time 1 failed to meet formal DSM- IV criteria at
Time 2. These children were excluded from the ADHD sample. Thus, we had 31 preschool children
diagnosed with ADHD (ADHD Combined type: n = 26; ADHD Hyperactive/Impulsive type: n = 5) and an
age, sex and socioeconomic status matched group of 31 preschool children without ADHD. Groups
were also equivalent in racial/ethnicity ratios: both groups were primarily Caucasian (81%) with African-
American (13%) and Latino (3%) comprising the remaining participants. (See Table 1 for complete
background data on both samples).

Preschool ADHD group

Given the controversies inherent in diagnosing ADHD in the preschool population, several precautions
were taken to ensure the validity of the ADHD diagnoses in our participants. Children were referred to a
general child psychiatry outpatient clinic and those that presented with chief complaints of “disruptive
behavior”, “overactivity” and/or “hyperactivity” were informed about our ongoing research study. These
potential participants were consecutive new referrals to a mental health clinic, which meant that these
children were a clinical sample free of prior assessment, diagnosis, or intervention. Upon referral and
expression of interest, the parents were mailed a behavior-rating inventory, the Behavior Assessment
Scale for Children — Preschool version (BASC; Reynolds & Kamphaus, 2004). Those who returned the
BASC and who had T scores on the BASC Hyperactivity scale ≥ 70 were invited for a formal diagnostic
interview. Our decision to use this cutoff score was guided by the recommendations in the BASC
publisher's manual, which designates a T score of above 70 as “Clinically Significant”. Those who did not
meet this inclusion criterion (n = 4) were thanked for their time and were assigned to an outpatient
therapist for assessment/treatment.

Thirty-nine families were invited for a DSM- IV based structured psychiatric interview. Two failed to
keep this appointment and thus, 37 families were interviewed using the Schedule for Affective
Disorders and Schizophrenia for School- Age Children (K-SADS-PL; Kaufman et al., 1997). Although
every effort was made to include as many caregivers as possible in the diagnostic evaluation, the vast
majority of reporters were mothers (n = 30) or grandmothers (n = 6). One father served as primary
informant. Six children failed to meet diagnostic criteria for ADHD and thus were excluded from the
study but were assigned to an outpatient therapist for assessment/treatment.

Participants were included in the ADHD group only if a consensus DSM- IV diagnosis of ADHD could be
reached. The Diagnostic Committee was composed of three board-certified child and adolescent
psychiatrists or licensed clinical psychologists who each have at least 10 years of experience diagnosing
psychiatric disorders. Diagnoses were assigned only if a consensus was achieved that criteria were met
to a degree that would be considered clinically meaningful. By “clinically meaningful” we mean that the
data collected from the structured interview indicated that the diagnosis should be a clinical concern
due to the nature of the symptoms, the associated impairment and the coherence of the clinical picture.
A key point is that our diagnostic approach paralleled the clinical assessment procedures for our
outpatient clinic; diagnoses were not simply reached by counting symptoms endorsed and applying an
algorithm.

The Diagnostic Committee was blind to the subject's group, all data collected from the baseline
assessment and all non-diagnostic data (e.g., cognitive functioning) collected from the follow-up
assessment. The Diagnostic Committee reviewed the audiotape of the interview and decided if the
preschool child had ADHD as well as other any other comorbid conditions. As is common in ADHD, most
children (n = 24) met diagnostic criteria for comorbid oppositional defiant disorder. In addition,
separation anxiety disorder (n = 10), specific phobia (n = 7) and generalized anxiety disorder (n = 2)
were diagnosed in our ADHD sample.

All 31 participants with ADHD who participated in the longitudinal study also participated in concurrent
outpatient mental health treatment. Fourteen of our participants were treated with combined
behavioral therapy and pharmacotherapy (9 participants were prescribed methylphenidate, 5
prescribed guanfacine). Thirteen of our participants were treated with behavioral therapy and no
pharmacotherapy. Finally, four participants were treated with pharmacotherapy only (all four were
prescribed methylphenidate).
Control group

Age, sex, socioeconomic and IQ-matched typically developing children were included as control
participants. Control participants were recruited from the same preschools as the clinic-referred
sample and were selected through a stratified random sampling procedure so as to be demographically
proportional to the participants with ADHD. Unlike our ADHD group, fewer families (n = 4) elected not to
participate in the project. Control participants were administered the BASC during screening and only
those participants with Hyperactivity scale T scores < 60 were included. Our decision to use this cutoff
score was guided by the recommendations in the BASC publisher's manual, which designates a T score
of above 60 as “At Risk”.

The socioeconomic status of our population was assessed with the Hollingshead (1975) scale. The
Hollingshead scale measures socioeconomic status via two factors: fathers' and/or mothers' years of
formal education and occupational prestige status. Our range in both groups spanned the entire range
of social class; however, the mean socioeconomic status of our two samples was equivalent and
represented middle to lower-middle class families.

Measures

 Behavior Assessment Scale for Children (BASC)

The BASC (Reynolds & Kamphaus, 2004) is a multidimensional measure of adaptive and problem
behaviors and has versions for preschool (4–5), child (6–11), and adolescent (12–18) age levels. All
participants in our sample received the preschool version of this instrument. Each of the 130 items of
the child version of the BASC is rated on a 4-point frequency scale, ranging from never to almost always.
The BASC yields T scores in broad internalizing and externalizing domains, as well as in more specific
content areas. The preschool version of the BASC has demonstrated satisfactory internal consistency
(Coefficient Alpha reliabilities > .90), test–retest reliability (intraclass correlation = .84) and has both
concurrent and discriminative validity (Reynolds & Kamphaus, 2004).

 Schedule for Affective Disorders and Schizophrenia for School- Age Children

This interview was utilized to identify the ADHD group, yet was administered to all participating
families. It was also used to capture the other major childhood psychiatric disorders as set forth in
DSM- IV that are often comorbid with ADHD, such as oppositional defiant disorder and anxiety
disorders. A board-certified child or adolescent psychiatrist or a licensed child clinical psychologist
conducted all interviews. At the outset of the K-SADS-PL, all psychiatric interviewers were blinded to
the child's diagnostic condition. A child and adolescent psychiatrist or clinical child psychologist
administered the K-SADS-PL. Based upon 23 randomly chosen audiotaped interviews, the kappa
coefficient was .92, signifying adequate inter-rater reliability.

 Wechsler Preschool and Primary Scale of Intelligence

The WPPSI-R is an age -standardized test of general intelligence intended for children age 3 years, 0
months to 7 years, 3 months. The WPPSI-R is comprised of 12 subtests (6 verbal and 6 performance).
Children's raw scores on each subtest were converted to scaled scores, which are normed to have a
population mean of 10 and a standard deviation of 3. In turn, the scaled scores are used to calculate
Verbal IQ score (VIQ) and Performance IQ score (PIQ), which are then combined to yield a Full Scale IQ
score (FSIQ). Each IQ score is standardized to have a population mean of 100 and a standard deviation of
15.

 Developmental Neuropsychological Assessment

The NEPSY is a comprehensive instrument designed to assess neuropsychological development in

preschool and school- age children ( ages 3–12). Scaled scores (M = 100; SD = 15) are provided for five
domains: attention/executive functions, language, sensorimotor, visuospatial processing and
memory/learning. Adequate psychometric properties have been reported for the NEPSY (Korkman et al.,
1998).

 Metamemory tasks

A metamemory question selected from Kreutzer et al. (1975) was presented to the participants:
“What if you were invited to a birthday party for a friend? How could you make sure you
remembered his party? Can you think of anything else you could do? How many different ways can
you think of?” (p. 29). The children's responses were scored in accordance with the criteria outlined
by Kreutzer et al. (1975). Scoring included (a) three categories of note (use of a prepared memory
aid, such as an invitation; a written record; and an object like a birthday present), (b) two categories
of self (active — attempting to remember; and passive — for example, will remember because of
excitement), (c) one category of other (asking another person to help one remember), and (d) one
category of put (indicating that reminders would be put in conspicuous places). For data analyses,
this metamemory task was operationalized on an ordinal scale according to how many categories
were mentioned in the child's response; this scale ranged from 0 (no categories were mentioned) to
7 (all categories were mentioned).

The experimenter wrote and audiotaped each child's responses; the audiotapes were used to
ensure that the transcripts were accurate and permitted a blinded second rater (graduate-level
research assistant) to simultaneously rate the responses. Based upon 46 transcripts, the kappa was .
93, indicating adequate inter-rater agreement. Intraclass correlation coefficients (ICC) were used to
assess the temporal stability of this task. Temporal stability was demonstrated via the solid (ICCICC =
.742, p < .001) relationships between Time 1 and Time 2 performance.

A second metamemory question pertained to the ability to estimate performance on a picture-learning

task. This task was modified from the task utilized by Yussen and Levy (1975). Each child was asked to
estimate the number of picture names that she or he would be able to recall in the correct order. The
pictures were the first ten pictures corresponding to the correct answers from the Peabody Picture
Vocabulary Test — Revised edition (PPVT-R; Dunn & Dunn, 1981). The initial ten items from the PPVT-R
were selected due to the greater likelihood that the items would be within the lexicon of children ages
3 and older (Dunn & Dunn, 1981). For data analyses, our second metamemory question results were
operationalized into three variables: predicted performance, actual performance, and the absolute
value of predicted minus actual (smaller numbers indicate better metamemory). Temporal stability of
this task was demonstrated via the solid (ICCICC = .707, p < .001) relationships between Time 1 and Time
2 performance.

Data Analysis

Informed consent/assent was obtained from parents and children under protocols approved by the
hospital institutional review board. Upon completion of the diagnostic interview and being assigned to a
group (ADHD, Control), children were assessed individually in a quiet room for approximately 3 h,
distributed between two separate assessments. Included in the two 90-minute assessments were two
10-minute breaks during which children could play games. The sequence of tasks was counterbalanced,
although the WPPSI-R and NEPSY were never given on the same day due to time constraints (both take
about 60 min to administer). Two licensed child and adolescent psychologists with experience working
with preschool children conducted the formal assessments. At time 1, the assessors were blind to
group assignment. A licensed psychologist or a trained assistant familiar with the measures double
scored all protocols.

Approximately one year later (M = 12.5 months, SD = .9 months; range 11–14 months), the research
protocol, including diagnostic interview, was repeated. Similar to time one, tasks were administered in a
counterbalanced fashion between participants. Attrition rates were low and 97% of our participants
completed time two assessments.

No participants were prescribed medications at Time 1 and all children were assessed off of their
medications at Time 2; a 24-hour washout period was required of all participants prescribed
medications. Most children were prescribed “drug holidays” on weekends; thus, study testing was
conducted on Monday mornings to more ethically manage the 24-hour washout period.

Limitations

There will some constraints in the sources of measurement will use to assess some constructs. For
example, although our metamemory instruments will precedence in the literature, our work should be
considered preliminary until other groups can replicate these results using psychometrically supported
measures.

We have a rather large number of families that did not wish to participate in the project. As a result, the
generalizability of our data may be limited and may not be reflective of the broader preschool ADHD or
disruptive disorders population. Additionally, many of our participants were not enrolled in formal
education; thus, teacher report data were not available and we relied solely on parent report of child
behavior. Our samples are rather small and although statistical significance was reached on our variables
of interest, the lack of differences on other variables (e.g., WPPSI-R) may be a function of low statistical
power. Our results should be considered preliminary until other groups replicate these results.

Conclusions
With limitations acknowledged, our data will suggest that despite having similar intellectual
abilities and comparable metamemory skills at age 4, preschool children with ADHD lag
behind typically developing children in metamemory skill at age 5. This finding is expected
with previous research in elementary school ADHD populations and will suggests that these
developmental lags may emerge prior to formal education. Voelker et al. (1989) also investigated
metamemory in ADHD and reported on 12 boys with ADHD ( ages 6–12). These authors
concluded that boys with ADHD had a utilization, not knowledge, deficiency. In other words,
children with ADHD had knowledge of how their memory works, yet failed to utilize strategies
which may improve memory recall. Miller and Seier (1994) reported that utilization deficiency
occurs during the earliest stages of strategy acquisition when a child spontaneously produces an
appropriate strategy but does not derive benefit. While our younger participants seem to have a
knowledge deficit, it is also quite possible that utilization deficiencies may emerge later in
childhood for children with ADHD.
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Appendix

Table 1. Mean (SD) scores at time 1 and time 2 for the ADHD and
control groups (N = 62)
Variable ADHD (n = 31) Control (n = 31)

Time 1 Time 2 Time 1 Time 2

Age 4.9 (.6) 5.8 (.5) 4.9 (.5) 5.8 (.5)

Sex (% girls) 40.1 40.9

Socioeconomic status 43.7 44.1

(11.6) (12.8)

WPPSI-R Full Scale IQ 94.3 93.7 98.5 98.3

(11.1) (14.0) (15.2) (14.9)

NEPSY Attention/Executive 87.7 87.0 97.4 97.9

Function (14.0) (12.8) (13.2) (13.3)

NEPSY Language 90.7 90.1 97.9 99.2

(13.3) (14.2) (13.3) (12.3)

NEPSY Sensorimotor 98.8 97.9 99.1 98.8

(14.2) (13.4) (12.9) (11.7)

NEPSY Visuospatial 100.5 99.3 99.1 98.9

(14.0) (13.1) (11.9) (11.1)

NEPSY Memory and Learning 89.3 89.5 99.1 100.0

(13.8) (12.8) (10.8) (14.8)

Note. WPPSI-R = Wechsler Preschool and Primary Scale of

Intelligence — Revised (Wechsler, 1989). NEPSY = Developmental
Neuropsychological Assessment (Korkman et al., 1998).
Socioeconomic status measured by Hollingshead (1975) scale.

p < .01 group differences at comparable time.