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Title
Self-Awareness assessment during cognitive rehabilitation in children with acquired brain injury: a feasibility
study and proposed model of child anosognosia.
Author names
Krasny-Pacini Agata1,4, Limond Jennifer3, Evans Jonathan3, Hiebel Jean1, Bendjelida Karim5, Chevignard
Mathilde2,4
Affiliations:
1. Institut Universitaire de Réadaptation Clemenceau-Strasbourg, 45 bd Clemenceau, 67082 Strasbourg,
France Paediatric Department and Hautepierre Strasbourg University Hospital, Strasbourg. France
2. Rehabilitation Department for Children with Acquired Brain Injury, Hôpitaux de Saint Maurice, 14, rue
du Val d’Osne, 94410 Saint Maurice
3. Mental Health and Wellbeing, Institute of Health & Wellbeing, University of Glasgow, Gartnavel Royal
Hospital, 1055 Great Western Rd, Glasgow G12 0XH , Scotland, UK
4. Sorbonne Universités, UPMC Univ Paris 06; CNRS,UMR 7371, LIB, F-75006 and UMR_S 1146, LIB, F-
75005, Paris, France
5. EMOI-TC 68, Hôpital du Hasenrain, 87 avenue d'Altkirch 68051 Mulhouse Cedex, France
Corresponding author :
Agata Krasny-Pacini
agatakrasny@yahoo.com; 0033671284152
agata.krasnygecam-alsace.fr; 00333882116 47 or 42
Institut Universitaire de Réadaptation Clemenceau-Strasbourg, 45 bd Clemenceau, 67082 Strasbourg, France
Declaration of interest
The authors report no declarations of interest.
Disclosure of funding received for this work
This study was supported by scholarships, from the “SOFMER” (French Society of Physical and Rehabilitation
Medicine), the “SFERHE” (French Research Society against Children’s handicap) and the “Fondation Gueules
Cassées”.
For Peer Review
SELF
-
AWARENESS ASSESSMENT DURING COGNITIVE
REHABILITATION IN CHILDREN WITH ACQUIRED BRAIN
INJURY: A FEASIBILITY STUDY AND PROPOSED MODEL OF
CHILD ANOSOGNOSIA.
Journal:
Disability and Rehabilitation
Manuscript ID:
TIDS-11-2014-053.R1
Manuscript Type:
Research Paper
Keywords:
self-awareness, cognitive rehabilitation, executive functions, children, brain
injury, model
URL: http:/mc.manuscriptcentral.com/dandr Email: davemuller@suffolk.ac.uk
Disability and Rehabilitation
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Implications for rehabilitation :
• Self-awareness has multiple components that need to be assessed separately, to better
adapt cognitive rehabilitation
• Using questionnaires and discrepancy scores is not sufficient to assess awareness, because it
does not include on-line error detection, which can be massively impaired in children,
especially those with impaired executive functions.
• On-line error detection is important to promote and error-full learning is useful to allow a
child to build a self-knowledge of his/her strengths and difficulties, in the absence of severe
episodic memory problems.
• Metacognitive trainings may not be appropriate for younger children who have age
appropriate developmentally immature self-awareness, nor for patients with brain injury if
they suffer anosognosia because of their brain injury.
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SELF-AWARENESS ASSESSMENT DURING COGNITIVE REHABILITATION IN
CHILDREN WITH ACQUIRED BRAIN INJURY: A FEASIBILITY STUDY AND
PROPOSED MODEL OF CHILD ANOSOGNOSIA.
AB S T R ACT
• Purpose: to compare three ways of assessing self-awareness in children with traumatic brain
injury and to propose a model of child anosognosia
• Method: five single cases of children with severe traumatic brain injury, aged 8 to 14,
undergoing metacognitive training. Awareness was assessed using three different measures:
two measures of metacognitive knowledge/intellectual awareness (a questionnaire and
illustrated stories where child characters have everyday problems related to their executive
dysfunction) and one measure of on-line/emergent awareness (post-task appraisal of task
difficulty).
• Results: All three measures showed good feasibility. Analysis of awareness deficit scores
indicated large variability (1%-100%). Three children showed dissociated scores.
• Conclusions: Based on these results, we propose a model of child self-awareness and
anosognosia and a framework for awareness assessment for rehabilitation purposes. The
model emphasizes (1) the role of on-line error detection in the construction of
autobiographical memories that allow a child to build a self-knowledge of of his/her
strengths and difficulties; (2) the multiple components of awareness that need to be
assessed separately; (3) the implications for rehabilitation: errorless versus error-full
learning, rehabilitation approaches based on metacognition, rationale for rehabilitation
intervention based on child’s age and impaired awareness component, ethical and
developmental consideration of confrontational methods.
IN T RO DUCTION
Metacognition is the conscious knowledge of one’s own cognitive processes as well as the processes
involved in consciously monitoring and regulating one’s ongoing actions [1]. Thus metacognition
refers to the awareness of one’s own cognition and is used in the context of normal functioning. The
concept of awareness/self-awarness (or more usually lack of awareness), on the other hand, is
usually used in the context of pathology and refers to the awareness of one’s deficits, including
cognitive deficits. As such, awareness can be viewed as metacognition applied to difficulties in
cognitive functioning.
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Awareness and metacognition have been defined in many ways and there is little agreement among
neuropsychologists, psychologists, developmentalists and education researchers as to the exact
nature and limit of the two concepts. In developmental psychology, metacognition is thought to
comprise metacognitive knowledge and metacognitive skills. Metacognitive knowledge is defined by
Flavell as knowledge about one’s own cognitive strengths and limitations, including factors that may
interact to affect cognition [2]. The concept of metacognitive skills, refers to the voluntary control of
cognitive processes including prediction, planning, monitoring and evaluation of behaviors.
Many models of awareness and metacognition have been proposed for adults [3]. Two models of
awareness/metacognition are particularly useful: (1) Crosson’s model [4] that offers a pragmatic
classification of awareness levels linked with efficient compensation which can be proposed in each
level and (2) Toglia and Kirk’s comprehensive model of awareness after brain injury [5].
Crosson’s model has an hierarchical structure, although this hierarchy has never been confirmed
empirically[6]. At the base of awareness is intellectual awareness. Intellectual awareness comprises
three sublevels: (a) the basic understanding that a deficit exists, (b) the recognition of a common
thread in the activities the patient is impaired in, (c) the implications this has. On-line Awareness
(also called emergent awareness) refers to the ability to recognize a problem while performing an
activity. Emergent awareness is crucial to rehabilitation as patients who do not realize that a problem
is occurring will not recognize the need to correct it and /or to initiate compensation. Anticipatory
awareness is the highest level of awareness in Crosson’s model, and is defined as the ability to
anticipate that a problem will occur as a result of some deficit, and take some action to prevent that
problem occurring.
Toglia and Kirk’s comprehensive model of awareness after brain injury views the relationship
between different aspects of metacognition and awareness as a dynamic process rather than as a
series of hierarchical levels. It clearly differentiates between knowledge and beliefs related to one’s
self (i.e. metacognitive knowledge that preexists and is stored within long term memory) and
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knowledge and awareness that is activated during a task (i.e. on-line awareness which Toglia and Kirk
define as “the ability to monitor performance “on-line”, within the stream of action”) [5].
Metacognitive knowledge is what one brings to a task, whereas on-line awareness involves ongoing
evaluation of performance within the context of a task [7][5]. Metacognitive knowledge and on-line
awareness are distinct functions and have been found not to be correlated in adults with brain
injury [8].
Although Crosson’s and Toglia and Kirk’s models offer two distinct frameworks to study awareness,
we argue they are complementary and that their combined use allows a better understanding of
patients’ difficulties: (1) Crosson’s Intellectual awareness corresponds to the metacognitive
knowledge of Toglia and Kirk’s model; (2) Crosson’s emergent awareness corresponds to on-line
awareness of Toglia and Kirk’s model (and comprises metacognitive “skills” from the field of
developmental psychology); (3) anticipatory awareness is the behavioral manifestation of good
metacognitive knowledge and good on-line awareness. Hereafter, the terms of awareness and
metacognition will be used interchangeably, postulating that they have the same underlying
construct, irrespective of its application to pathology or to normal functioning. Correspondence
between the models and vocabulary used in developmental psychology are summarized in figure 1.
Insert Fig 1 about here
Impaired awareness/metacognition, sometimes also termed “anosognosia”, is a common
phenomenon described in children who have sustained a traumatic brain injury (TBI) [9][10][11].
However it results from a combination of organically based unawareness (due to brain injury) and
simple developmental immaturity [11] present in typically developing children as well. Metacognition
is known to be poorer in younger children. Even typically developing children are not “fully aware”:
they may have some basic intellectual awareness about things they cannot do that their parents can,
however they are not able to fully understand the consequences of their cognitive limitations in
recognizing a problem when it is actually happening, or predicting a problem will occur as a result of
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some developmental immaturity. Children only gradually come to gain awareness over the entire
span of developmental years [11]. This has been mainly studied in relation to memory (termed meta-
memory) in typically developing children who show gradual development of metamemory
throughout childhood [12]
,
[13]
,
[14]
,
[15]
,
[16] and in the field of learning disabilities [17]
,
[18]
,
[19][20]. Nelson and Narens proposed a comprehensive model of metacognition in metamemory
[21] where metacognition is described as the interplay between two levels of information processing
(an object-level processing and a meta-level processing) that interact with feedforward and feedback
control and monitoring loops . A neural description of the model has been proposed by
Shimamura[22].
To the best of our knowledge metacognition in relation to other cognitive functions, and especially
executive function (EF)/complex task management in daily life, has not yet been explored
.
Here we
will focus on metacognition for executive functions and complex task management in children with
TBI because EF deficits are a frequent and disabling consequence of TBI [23] [24]and because TBI
outcome is strongly predicted by executive functioning level[25].
Although metacognition is poor in young children, it has been shown to be even poorer in children
who have sustained a brain injury [9][10][11][26][27][28]. However, to date, objective measurement
of awareness in children with TBI is scarce (see Wales et al. [29] for a review) and most studies
evaluate single metacognitive skills such as prediction, evaluation and confidence of performance[30]
[31] [32] [33] [34]. Conversely, Beardmore et al. reported the use of the “Knowledge Interview for
Children” (KIC) [9], a semi- structured interview related to twelve areas of knowledge about TBI
(coma, story of the accident, brain functioning…) and ten potential areas of difficulty (attention,
fatigue, memory, behavior…). Interview of the child and the parents yields an Awareness Discrepancy
Index, by summing the number of items endorsed by the child’s parents but rejected by the child.
Children reported significantly less problems than their parents and demonstrated extremely limited
knowledge about TBI. The SAND-C (Subjective Awareness of Neuropsychological Deficits
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Questionnaire for Children) is a self-report instrument in which children are required to estimate
their neuropsychological functions [25], however self report is not compared to parental judgment
and as such is not a measure of anonosgnosia if used alone.
Josman et al. evaluated children with TBI in relation to metamemory [31]and categorizations skills
[35] with three types of self-awareness measures (1) intellectual awareness –termed general
awareness by the authors (e.g.: “have you noticed any changes in memory?”), (2) self-prediction (of
task difficulty[35]; “how many pictures will you remember ?” [31]) and (3) self-estimation of
performance after the task. General awareness questions were not fully understood by the children
and therefore not recommended. Prediction was difficult in both healthy children and children with
TBI, self-estimation was significantly less correlated with actual performance in brain-injured children
than in typically developing ones [35], and children with brain injury overestimated their memory
performance [31]. Similarly, in Hanten et al. [32] [33] and Crowther et al. [34] studies, children who
had sustained a TBI had poor estimation of their memory span and overconfidence in performance
when compared to healthy children and children with mild TBI [32], suggesting impaired
metacognition. The scarce literature assessing awareness in children with brain injury explores
metacognitive skills such as prediction and evaluation, using assessments performed in structured,
un-ecological environments. Questionnaires of intellectual awareness (KIC, SAND-C) proposed to
date are not domain specific and do not specifically explore awareness of executive functioning.
The use of metacognitive training is a practice standard in adults with deficits in executive
functioning [36]. Adult metacognitive training programmes, such as Goal Management Training
(GMT) [37] have begun to be used in children[38]. GMT is mostly known for its algorithm “STOP ! -
Define the main task – List the steps –Learn the steps – Do it - Check” that can be used to train
specific tasks [39]. However, the full GMT version [40] is a truly “metacognitive” training in that GMT
encourages patients to think about their cognitive failures, to identify factors promoting or
preventing these failures and to reflect and monitor how their thoughts may drift away from the
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main goal and switch to “automatic pilot”. When used alone, GMT group training [41] [40] does not
offer a repetitive intensive practice of EF and monitoring skills, but rather teaches and prompts the
patients to monitor their actions, to detect their cognitive slips and gain control over their actions,
through a conscious and attention-demanding monitoring of their flow of thoughts and actions. The
relatively short duration of the programme (7 x 2 hours of group training in adults, including GMT
theory presentation and group discussions) does not allow automatisation of monitoring and
checking. Rather, it relies on patient’s awareness of difficulties and ability to actively implement the
GMT algorithm in daily life, under conscious and ‘top-down’ control. Therefore GMT in adults relies
heavily on a patient’s awareness. A patient who considers that his/her cognition is efficient, will not
easily engage in such an attention-demanding programme aiming at improving cognition efficiency in
an effortful way. Awareness (before treatment or acquired throughout the GMT programme) is a
core factor for programme success. GMT programmes usually enroll patients with mild or moderate
brain injuries with relatively preserved awareness or integrate an awareness intervention component
before the GMT [42][43].
As young children with brain injuries have impaired awareness because of developmental immaturity
[11] added to the organically based awareness deficits due to their injury, metacognitive training
programmes such as GMT may not be effective because the core factor for programme success –
awareness – is missing. It is therefore crucial to evaluate children’s awareness when conducting a
metacognitive training such as GMT. To our knowledge there is a lack of self-awareness measures for
children. Tools used in metacognition developmental research [44] [17] [45] [21] are not easily
accessible or transferable to the context of rehabilitation (e.g.: use of event-related potentials)[44].
Furthermore, as cognitive rehabilitation of EF aims at understanding and improving daily life
executive functioning in the natural context of the child, classically used measures of metacognition
(Judgments of Learning - JoL; Ease of Learning judgments – EoL; Feeling of Knowing – FoK; during a
word list learning, in an office-based un-ecological environment [21][12][13][14] [15][16]) are not
clinically useful.
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The primary aim of this pilot study was to examine the feasibility of three ways of assessing
awareness of executive dysfunction in children with a TBI during a rehabilitation programme based
on GMT.
ME T H ODS
This awareness study was part of a pilot study that tested an intervention based on a context-
sensitive pediatric Goal Management Training (GMT) combined with ecological activity practice.
Details and effectiveness of the intervention are reported elsewhere [38]. Children were taught
metacognitive strategy use through discussion of stories in which story characters experience
cognitive failures. Children were introduced to ideas of how those may be prevented, and were given
practice at applying metacognitive strategies on paper-and-pencil exercises, then on ecological
activities in the rehabilitation centre, and finally on real life activities at home and school. The
programme used a range of functional, meaningful activities including cooking. The training was
administered weekly, for 15-20 hours over 4-6 months. Because of the availability and time required
by the intervention for the children included in this pilot study, it was not judged ethically possible to
include typically developing children. Children included in the study had sustained a severe TBI at
least two years earlier, had a documented dysexecutive syndrome, including executive functioning
difficulties in daily life as reported by parents and school staff.
Awareness was assessed using three different measures: two measures of metacognitive knowledge
(intellectual awareness) and one measure of on-line/emergent awareness.
The two measures of metacognitive knowledge (MK) corresponded to two different levels of
Crosson’s intellectual awareness (see figure 1). The first measure assessed level (a) of Crosson’s
intellectual awareness i.e. the basic understanding that a deficit exists. The second measure assessed
levels (b) and (c) of Crosson’s intellectual awareness i.e. (b) the recognition of a common thread in
the activities the patient is impaired in and (c) the implications this has.
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The first measure of MK (the basic understanding that a deficit exists) consisted of a discrepancy
score using the “goal management training questionnaire”[40] translated into French, simplified and
adapted for children (see appendix 1). This questionnaire, based on the adult GMT questionnaire, is
specific to goal management difficulties and ‘goal neglect’ (failure to take actions to achieve goals
despite the intention to do so). It is however not validated and has no norms. Because poor reading
skills and vocabulary might have influenced children’s responses, the questions were read to the
child who answered orally. The questionnaire presents common executive failures that can happen
at home, at school or during leisure activities (e.g. “Forgetting something that needed to be done at a
certain time , running out of time because you got too caught up in something that you were doing,
starting an exercise and realising once you’ve started that are not doing what was asked...”). For
each of the 30 items of the questionnaire, the child had to report if the item was a problem for
him/her. The questionnaire was answered during an interview with the child without his/her parents,
before the intervention. The trainer provided age-appropriate examples for the items the child did
not understand spontaneously. At the end of the intervention the same person who trained the child
throughout the rehabilitation programme, answered the questionnaire as well, based on what she
witnessed of the child’s behavior during the intervention and based on contacts with parents and
school. As the trainer had spent 15-20 hours with the child, it allowed her to observe carefully the
child’s functioning. The questionnaire score of MK awareness was obtained similarity to the KIC[9],
from the number of discrepant items between the child’s rating of the questionnaire and the rating
of the trainer. An item was judged as discrepant if the child responded it was not a problem, or a
minor problem but the investigator thought it was a significant problem, obtaining a binary response
for each item (aware/unaware). Potentially inversed discrepancies (the child thinking an item was
problematic while the trainer responded it wasn’t) did not occur. Items not relevant (e.g. forgetting
books in the school bag, when school bag is not prepared by the child) were excluded, as well as
items the examiner could not judge reliably at the end of the intervention. The final score was a
percentage of “unaware items” divided by the number of relevant and reliable items.
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The second measure of MK (the recognition of a common thread in the activities in which the patient
is impaired and the implications this has) used stories contained in the pediatric GMT
intervention[38] , and was assessed throughout the intervention. In these stories, characters have a
series of daily life problems related to their executive dysfunction (e.g. putting an essay to hand in at
school into a sports bag instead of a school bag). Stories are age-appropriate and consequences of
the problems are emphasized (e.g. stress while looking in the school bag for the essay, feeling upset
when finding the essay in the evening while getting dressed for football, getting a lower mark
because the essay was handed in late…), as well as factors that contributed to the problem (e.g.:
going to bed late because writing the essay at the last minute, being in a rush when preparing the
school bag and the sports bag the next day). Use of PowerPoint slides with child friendly drawings,
allowed children to follow the story without too much pressure on their working memory. The
intervention contained a total of six stories, one every two weeks. At the end of each story, the child
was asked “Do you think this could happen to you?” and it was followed by a discussion with the
child about personal examples of cognitive failures and slips (called “Oops errors” in the
intervention), implications and factors that contributed to these “Oops errors”, and similarities with
the stories. The awareness deficit score was the percentage of stories the child thought would never
happen to him/her, while the trainer saw similar events regularly happening to the child, divided by
the total number of stories. A child who acknowledged that this kind of story could have happened to
him/her, but could not provide any personal examples of similar cognitive failures, was still
considered as being aware on that story (i.e. providing personal examples was not mandatory to
score as aware on a story).
Emergent (i.e. on-line) awareness was assessed throughout the intervention by asking the child at
the end of each session if s/he thought the exercise/activity had been difficult for him/her. Exercises
could be office-set paper-and-pencil school type exercises or complex daily life tasks like real
cooking. An awareness deficit was taken as a percentage of activities judged by the child as easy
while s/he completely failed or required a lot of help to achieve the goal, divided by the total number
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of intervention sessions. On-line awareness assessment was conducted throughout the training, at
the end of each session, with a total of 15 sessions. Children were also asked to identify “Oops
errors” (cognitive slips) s/he had made during the exercise/activity, to qualitatively assess their on-
line awareness.
Because awareness measures (except the questionnaire) were embodied in the intervention
program, throughout the 15-20 hours of training, it was not possible to obtain data from healthy
controls who did not follow the intervention on those specific awareness measures.
Although this was not intended to be part of the awareness assessment, we also report here the
behavior of children during a pre-intervention test using cooking, the Children’s Cooking Task[46]
[47] (CCT). In the CCT, children have to make a chocolate cake following a child-friendly photo-cued
recipe. Children repeated the test twice before the intervention (to obtain two baselines). Children
were not asked about their performance on the CCT because it would have acted as a cue for
subsequent CCT assessments. However as behavior gave the trainer some insight into children’s on-
line awareness through error detection on task, and possibly anticipatory awareness on the second
attempt to make a chocolate cake (for second baseline), trainer qualitative observations are
reported.
RE S U L TS
Five children were initially included in the study. One child (YR) dropped out after four sessions.
Children’s detailed medical history, neuropsychological assessments and overall intervention effect
can be found in table 1. All children suffered a severe dysexecutive syndrome, especially on
ecological measures of executive functions (Children’s Cooking Task and questionnaires).
Neuropsychological assessment showed relatively preserved or even normal episodic memory (see
table 1- except for RK, in story recall which was poor probably due to attention rather than memory
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problems) therefore high anosognosia scores in the stories and questionnaire did not reflect a
memory problem.
Insert Table 1 about here
FEA S A BILITY
Our method of awareness assessment showed good feasibility. For the first measure of MK, all
children were able to understand the thirty-one items of the questionnaire when provided with
examples. The maximum number of items per child the trainer could not reliably assess at the end of
the intervention was two. For the second measure of MK (stories), children enjoyed GMT stories and
could understand them easily. All stories could have happened to the children and were relevant.
Children could identify no “Oops errors” in activities they had judged as easy, even when they had
failed the task.
AW A R ENESS SCORES
Awareness deficit scores for each type of awareness are presented in figure 2. Higher scores indicate
that children are more anosognosic/unaware, i.e. representing a deficit in awareness. Lower scores
reflect better awareness.
Insert Fig 2 about here
QU A LITATIVE DA T A
CH I LD 1: YR
YR was 14. He had sustained a severe TBI at the age of 2.5 years (collision with a running child); he
attended a special school but was excluded from school for half of the year for behavioral issues. YR
dropped out from the intervention after 4 sessions.
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YR reported none of the questionnaire items as problematic, despite having been observed making
frequent errors, resulting in a 100% awareness deficit score. As for pGMT stories of the modules he
completed before he dropped out of the study (4), YR thought the characters must be “stupid” and
such cognitive failures would never happen to him and never gave any example of personal ”Oops
errors” in the story discussion, nor did he acknowledged he made mistakes or errors in the ecological
intervention activities. An example is his performance on the CCT (Children’s Cooking Task) prior to
the intervention: YR found the correct recipe easily, took a quick look at the ingredients needed, put
all the eggs he could find on the table, all the baking powder (5 packets), added one spoon of
chocolate and one spoon of flour and put it in the oven. At the end of the task, both the child and the
examiner tasted the “chocolate cake” that was rather a baking powder-flavored omelet, provoking
instantaneous tingling in the mouth. YR said: “I didn’t know it was so easy to make a chocolate cake.
But next time I’ll put slightly more chocolate” and wanted to eat the remaining cake. After being
shown that on the same page there were stepwise instructions and asked if he thought he had
followed them, YR looked perplexed for a moment and said in a defensive voice “No, I didn’t but I’ve
managed well anyway”. YR made it clear he was not interested in the training and that he needed no
help. However he was very interested in the module that explained executive function impairment
and spontaneously admitted “That’s exactly my problem”, suggesting some intellectual awareness
but then returned to a contemptuous attitude for the training. Before he dropped out of the study,
YR participated actively in the sessions, while affirming he participated only because his parents
forced him and that he had no need for it.
CH I LD 2: PB
PB was 11. She was a passenger in a motor-vehicle accident at the age of 2.5 years with severe brain
lesions requiring immediate neurosurgical treatment. She attended mainstream school with a part-
time school assistant. She had epilepsy absences treated by carbamazepine. PB was intellectually
aware of her impairment on nearly all items of the questionnaire. Indeed, she understood she had
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difficulties with some activities, (lowest level of Crosson’s intellectual awareness) and answered to
most items in the questionnaire as “big, big problem for me”, but she seemed unable to understand
the implications of her deficits (highest level of intellectual awareness). While enjoying the GMT
stories very much (our second measure of MK), PB never acknowledged such things could happen to
her. For example, she recognized she often forgets and loses important objects (at school, she is late
half of the time because she realizes on her way to school that she didn’t take her schoolbag; she
doesn’t give forms to be signed by parents to her mother, who then misses important school
meetings). However these situations did not seem problematic to PB, and there was no emotional
reaction when these failures were discussed in relation to the stories. PB regularly took examples of
her highly organized mother’s rare executive failures as an excuse for her own frequent failures: “My
Mum sometimes forgets her bag as well”. As for on-line awareness, she judged most of the activities
as easy, even when she needed considerable help to manage them. She never recognized she failed
an activity and it was thus impossible to convince her that the training could help her. In the CCT, on
her first attempt to make a chocolate cake she forgot the baking powder. On her second attempt,
she focused on not repeating the same error and managed a beautiful looking cake, containing the
baking powder, but this time missing sugar. While still unable to acknowledge the need to
compensate for EF dysfunction at post-intervention testing, she was reported to have made
significant progress on parental and teacher post-intervention questionnaires (see [38]) and parents
were highly satisfied with the intervention, reporting that she understood her brain functioning
better.
CH I LD 3: CS
CS was 11. She had sustained a TBI when a soccer goal post fell on her head at the age of 6.5 years,
with mainly cerebellar and right parieto-occipital lesions. She attended a special school and a
mainstream school part-time. Her intellectual quotient was on the lower limit of normal and she had
impaired theory of mind and language pragmatics described in her previous rehabilitation reports. CS
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was aware of most problematic items of the questionnaire i.e. basic intellectual awareness. In our
second measure of MK (stories), CS acknowledged all of them could have happened to her. However
her behaviour indicated that she often simply “guessed” that she was expected to say “yes, that
story could have happened to me” and she could not provide any personal example of a similar
“Oops error” in the discussion that followed the stories. She couldn’t evaluate her performance “on-
line“ during or after activities, did not express awareness of “Oops errors” after the tasks and always
thought activities were easy and that she did well, although she failed or needed much help on most
tasks.
CH I LD 4: IP
IP was 8 at the beginning of the training. A television had fallen on his head at the age of 5.5 years.
He attended mainstream school with a part-time school assistant. He was diagnosed with ADHD,
with symptoms that had probably started prior to the TBI. Very protected by his carers, who
confronted him as little as possible with his difficulties (e.g.: managing his schoolbag preparation), he
had few opportunities to notice that he was impaired and lacked knowledge about the consequences
of his TBI. All three measures of awareness showed a moderate awareness deficit, with highest
unawareness for on-line awareness. Very few examples of personal “Oops errors” could be obtained
from IP and most of these were not appropriate. On his first attempt to make the chocolate cake, he
used a small coffee bowl instead of the required salad bowl: after pouring in the sugar, the bowl was
full, however he continued adding the other ingredients until the bowl was invisible and totally
covered under a mountain of flour. He showed no manifestation of having detected this error and
was very surprised when he looked at the photo of the next step of the recipe, depicting a half full
salad bowl of cake mixture. He also had difficulty following the recipe steps and missed the step
requiring to stir the mixture until it was smooth. He was very surprised that, once cooked, the “cake”
had separated into white-flour and a black-oily layer. During training sessions, he alternated from
great overestimations of his abilities (“I’m the most intelligent boy of my class, this exercise is just
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too easy”) to deep self-depreciation (“I can’t do it because I’m just too stupid”) and presented great
emotional reactions to his performance, including inconsolable crying when he was failing a cooking
recipe, inappropriate laughing, and rolling on the floor when he could not find a solution to a
problem.
CH I LD 5: RK
RK was 13. He had sustained a motor-vehicle pedestrian accident at the age of 7. He attended part -
time private schooling with school assistant part time private lessons. He presented with severe
attention problems. Although 13 at the time of the study, his parents could never leave him at home
alone, he was forbidden to enter the kitchen as he usually forgot to switch off the gas. RK was fully
aware of his impairments on all three measures. He is the only child who actually acknowledged the
utility of strategies taught during the intervention and used them to compensate for EF dysfunction
post-intervention. However effects did not transfer to natural contexts and no change was reported
by parents on post-intervention questionnaires [38]. However he seemed unaware of his lack of
cognitive flexibility. This was illustrated by a cooking episode at home reported by his parents. He
decided to make finger biscuits (that he had practiced during the intervention) for his large family. He
decided to multiply all ingredients by 5 (which would give over one hundred biscuits), because it
would require 500 grams of butter which is the usual size of butter packs found in shops. His parents
tried to persuade him that this would be too much and that multiplying recipe quantities by two
would suffice. He could not accept it, even though there was no problem with mathematical skills
and he refused to make the biscuits at home with any other quantity. A whole intervention session
focused on this problem without success.
DI S C U S S ION
All three methods of awareness assessment showed good feasibility. Apart for one child who
presented complete anosognosia on all awareness measures (YR), children showed relatively
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preserved basic intellectual awareness but more difficulty in the higher order intellectual awareness
and on-line awareness. Observation of the cooking activity on the CCT allowed an interesting insight
into the children’s awareness and especially error detection.
ME A S U R ING MET A C O G N ITIVE K N O W LE D GE/ IN T E L L E C TUAL AW A R E N E S S
Many ways of assessing awareness in adults have been described in the literature (see Ownsworth
and Clare [48] for a review). Intellectual awareness is commonly assessed through discrepancy scores
between the patient and a significant other’s rating on a questionnaire (e.g. Dysexecutive
questionnaire[49], Patient Competency Rating Scale[50][51] , Awareness questionnaire[52]). Self-
report versus test performance is another way of assessing intellectual awareness. Our approach was
a discrepancy score approach but was close to the self-report versus test performance approach, as
the therapist was the informant, and most items judgments were based on children’s actual behavior
and performance throughout the sessions. The questionnaire was easily understood by all children
and, as the informant was the therapist (taking into account interviews of parents and school staff),
we probably managed to have a more objective informant report than when parents answer
questionnaires alone. However, the questionnaire was long and items related to the content of the
intervention (Context-sensitive Goal Management Training[38]), that focused on improving executive
functions and prospective memory. This questionnaire would need to be shortened and simplified
further if applied to cognitive rehabilitation outside GMT training context.
Crosson’s levels of intellectual awareness proved useful in explaining PB’s dissociated intellectual
awareness: excellent awareness of impairments on the questionnaire (lower level of intellectual
awareness) but difficulty in recognizing common threads between activities she is impaired in (on the
GMT stories) and total unawareness of the consequences of these impairments (highest level of
intellectual awareness) when these were discussed during training sessions. The difference between
the two levels of intellectual awareness described by Crosson: (1) knowledge of impairment and (2)
implications of impairment is probably a key issue in research with children. PB could state her
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impairments well, but did not see the implications of them - and thus did not acknowledge the need
to compensate for them.
The GMT stories offered the advantage of presenting to the child both impairment and its
consequences in an accessible story, with a visual support that lowers working memory and language
demands. Through these stories of daily living, we hoped the child would understand the cognitive
failure and its consequences and use it to recognize how cognitive failures may impact on home,
school and leisure activities. Children found the stories fun and understood them easily, as opposed
to more general questions that have been used to assess intellectual awareness in children [31][35].
However, this approach for assessment of awareness requires intact theory of mind (ToM) skills. First
level ToM is needed to adequately understand how the character thinks and feels in relation to the
situation. Second level ToM is needed to understand what the character thinks the surrounding
characters are thinking (e.g. a story where a boy forgets the ball he was supposed to take to a
football match with his friends, who become angry with him). Unfortunately we did not assess ToM
in participants, nor did we ask control questions to check if the children had sufficient ToM ability to
fully understand how the character is feeling. As children who sustain a TBI can suffer impaired ToM
[53][54], such an assessment should control for ToM. A way to control for ToM would be to ask the
child how the character is feeling instead of including this information in the text of the story. For
example CS, who was described in her medical reports as having poor ToM, had difficulty
understanding the stories. She could not give personal examples of similar events, and struggled to
understand how the reaction of characters in the story related to cognitive failures. She also did not
appear to be aware of the consequences of the cognitive slips. However, she often answered that
“yes that story could have happened to me”, relying on her knowledge that she often does things
wrong and she simply “guessed” what she was expected to say. Therefore her story score seemed
unrealistically good and therefore unreliable, probably because of her reasoning and ToM
impairment . ToM has shown to be correlated to self-awareness [55] in adults and must be assessed
if stories are used to assess metacognition. On the other hand, some authors proposed that
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metacognition and awareness reflect ToM about one’s own thoughts [56][57], and that both rely on
the same cognitive ability and common brain structures[58]. Another problem with using stories to
assess awareness is that the measures can be biased by children’s incapacity to generalize the
situations presented to other similar situations where the same cognitive failure can occur.
ON - L INE AWAR E N E S S
ME A S U R ING ON - LI N E AWARENESS
On-line awareness is difficult to assess. In the literature several approaches have been described: (1)
think aloud protocols (the child is told to say aloud everything he/she is thinking [59]; (2) video
analysis of performance where the examiner looks for signs of error detection (verbalization, non
word exclamation such as “oops!”, facial expressions, head-shaking, manual gestures) in the patients
behavior[60]; (3) forced on-task verbalization of error detection (e.g: patient instructed to say “hit”
whenever he/she notices that he/she made an error)[8]; (4) event-related potential examination
during task [61]. Think aloud and forced on task-verbalizations are problematic in that they inevitably
become a dual task paradigm and/or a prospective memory task: They require additional attention
allocation to the task of showing the examiner an error has been detected. Furthermore in both
these approaches, as the patient is informed of being assessed/watched on his/her error detection
skills, s/he is likely to focus on error detection rather than the task itself, and as a consequence
provides an unecological (and thus inaccurate) measure of error detection capacity in daily tasks.
Conversely, behavioral signs of error detection probably underestimate error detection, as very early
detected errors and errors with little consequences are unlikely to be expressed by overt behavior,
especially if the patient wants to appear successful. Event-related potential (ERP) offers an
alternative way of assessing error detection[44]. Following an error, an error-related negativity is
registered, that has been argued to correspond to the unconscious (implicit) error detection,
whereas conscious errors are followed by a positive deflexion [44]. This post-error positivity is
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reliably associated with decreased on-line awareness of deficits [62] and was proposed as an
electrophysiological indicator of on-line awareness in adults. ERP studies suggest that a child may
have no experience of making an error, either because s/he truly does not detect errors, or because
implicitly detected errors are not brought to consciousness. From a rehabilitation point of view, it has
consequences as to where to focus intervention: it seems illogical to try and make children
consciously aware of errors they haven’t detected “electrophysiologically”, at a basic, unconscious
level. From a developmental point of view, it is interesting to note that the error-related negativity
that follows all errors (conscious or not) has been shown to increase with age, whereas the
subsequent positive deflexion (present only for conscious errors) – marker of on-line awareness –, is
stable with age. Although theoretically promising, ERPs are impractical to use during rehabilitation
sessions and will probably remain a research tool rather than being used routinely for clinical
purposes.
TR U L Y “ON LIN E ” V ERSUS “OF F- L I N E ” AWARENESS : PREDICTIO N A N D EVALUATI O N O F
TA S K PERFORM A N C E
In our study we tried to find a way of assessing on-line awareness, without disrupting the ongoing
task. Our measure of on-line awareness (responses to the broad question “Was the task difficult for
you?” and post-task error recollection) had the drawback of requiring preserved memory of
performance, as children were asked the question only after the task. It relied on post-task
evaluation, rather than “truly on-line” error detection and was therefore rather a measure of “off-
line” awareness. The term “off-line “ metacognition/awareness has been proposed by Desoete [17]
in her study of metacognition in math problem-solving. Off-line metacognition includes both
prediction (of difficulty, of time required to complete the task) and post-task evaluation of
performance. Emergent/on-line awareness can be considered to comprise truly ”on-line” awareness
(error detection, monitoring of performance during the task) and off-line awareness (immediately
before and after a task). Off-line is included in on-line awareness because it is activated within the
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context of a specific situation or task and involves judgments about one’s abilities and limitations in
relation to the current situation. Furthermore a complex task such as cooking is a series of subtasks
and therefore predictions, error detection and monitoring and evaluation are continuously needed
throughout the task: as such off-line awareness is needed throughout the task.
PR E D I CTION O F P ERFORMANCE A N D ANTICIPA T OR Y AWARENESS
The exact distinction between prediction of performance and anticipatory awareness is unclear in
the literature and therefore the two terms are sometimes used interchangeably. Our view is that
prediction of performance is a skill, which can be prompted and is cognitive in essence. Anticipatory
awareness is the behaviour that results from spontaneous, correct prediction of task difficulty and of
self-capacity to deal with the task. Anticipatory awareness is very difficult to capture in an
assessment because it is a behaviour rather than a measurable cognitive function. Anticipatory
awareness is expressed when the potential for a problematic situation/task arises in daily life. All
attempts to capture anticipatory awareness in an office-based interview or assessment are
unecological, because asking the patients how they perceive their ability in a hypothetical situation
provides a prompt for awareness and assesses intention of behaviour. It does not reflect actual
behaviour in such a situation, in daily life, and in the patient’s usual environment. Most assessments
termed “anticipatory awareness” assessments are really “off-line” prediction awareness measures
(e.g.: asking the patients : “how do you think your performance on the task might affect your ability
to live independently, work and have fun?” [6]; or predicting memory span[8]).
In our study, none of the three measures of awareness served to assess prediction or anticipatory
awareness. However qualitative observation of children’s behaviour gave some insight into their
anticipatory awareness, especially on their second attempt on the CCT. For example PB, who had
only very basic intellectual awareness, could predict she might forget baking powder again and thus
concentrated on adding the baking powder on the subsequent CCT attempt.
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Anticipatory awareness probably has different levels as suggested by PB: she could anticipate she
would forget the baking-powder (lower level of anticipatory awareness, in this case “baking powder-
specific”), but could not generalise this anticipatory awareness to other ingredients she might forget
(higher level of anticipatory awareness, “ingredient-specific”), or to the anticipation that she may
forget not only ingredients but whole recipe steps, switching on the oven (highest level of
anticipatory awareness), or even more broadly that she is very disorganised irrespective of the type
of task (generalised anticipatory awareness , in other activities such as cooking in general, do-it-
yourself, homework…).
DE T E CTING ERR O R S ON-LINE A N D ERRORLESS L EA R N I N G
Another issue for our measure was the help given to children on the tasks. For unfamiliar tasks such
as cooking, the considerable help provided by the trainer probably seemed natural to children and –
with the help received – the task might be perceived as “easy”. On-line awareness can probably be
experienced only if a patient is allowed to struggle on task, which was not the case during the
intervention, as our first aim was to train children in novel complex task management, and only
secondly to assess awareness. This issue is particularly important as some authors advocate errorless
learning for patients with dysexecutive syndromes[39]. Classically, errorless learning has been used
in patients with memory deficits: Errorless learning is based on the assumption that explicit memory
for errors is impaired, whereas implicit memory is not, meaning that errors are primed, and so are
more likely to be repeated. In errorless learning instructions, the aim is to try to prevent patients
from making errors during the learning process. However it has also been proposed to use errorless
learning in patients with a dysexecutive syndrome without memory deficits. In those patients,
errorless learning is based on the assumption that the error-monitoring system is defective [63][64],
whereas implicit memory is not, yielding a memorisation of the undetected error. In errorless
learning patients are not given the opportunity to detect their errors because errors are prevented
by the therapist. It is possible therefore that this could impair the development of on-line awareness
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by ensuring success on tasks at all times and offering no opportunity for the error-monitoring system
to be trained/used. Therefore error-based learning has been proposed to improve self regulation in
adults with ABI[65]. Error-based learning may be useful in helping children to develop their on-line
awareness through error detection, but this must be considered carefully and evaluated for children
with severe episodic memory impairments, who may not remember the error they detected and
therefore may profit more of an errorless learning approach. It would be interesting to include an
assessment of awareness (and especially on-line awareness) in trials comparing errorless and error-
based learning.
STE P S REQUIRE D F O R CORRECT P O S T - TASK EV AL U AT ION
Post-task evaluation was influenced by different factors in our study, and not only error detection
ability. Qualitative analysis of on-line awareness measures, based on the performance of the five
children on the ecological training activities and on the Children’s Cooking Task lead us to propose a
series of steps necessary for adequate post-task evaluation, (where error detection is only the first
step). Figure 3 presents examples of children’s (real or hypothetical) verbalisation for each step,
corresponding to a situation where the child is aware. In our view, a child must go through all the
steps to truly experience the difficulty of having trouble with a task (i.e. on-line awareness). We
suggest that to understand a child’s on-line awareness deficit in rehabilitation, each required step
should be assessed separately (see bottom line questions in figure 3).
Insert Fig 3 about here
The consecutive steps are: (1) Errors must be detected and brought to consciousness (see previous
section on measuring on-line awareness); (2) Even if the error has been consciously detected on-
tasks, a child may have no memory of having performed poorly on the task because of episodic
memory impairment (she/he does not encode performance on the task in episodic memory or does
not encode it as an error or cannot access the memory). Even if an error is detected and
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remembered after the task, children may (3) not appraise the consequences/implications of the
errors and therefore not interpret them as errors (errors with little consequences, or unknown
consequences or corrected errors not being considered as errors) resulting in a very positive self-
evaluation of performance; (4) neglect the main goal of the task. These last two factors are probably
extremely important in children, as they tend to focus on things that went right or that were fun,
rather than on errors which are thought of as minor details. All children had so much fun trying to
make a chocolate cake in the CCT, that even totally failed cakes were given a positive appreciation by
the child who made them: IP did not know that not mixing the liquid and the flour would result in an
inedible cake. He could not make a connection between the cake consistency and his omission of
mixing the ingredients (erroneous appraisal of consequences of the error). YR was pleased with his
‘baking-powder omelette’, although he acknowledged he was supposed to follow the recipe steps to
make a chocolate cake (neglect of main goal); (5) For some children, in spite of adequate recognition
of within-task errors, there is an inability to relate these apparently unique errors to previous similar
experiences, nor to anticipate potential future situations where the same problems are likely to
occur, impeding the child to generalize his/her on-line experience.
It is worth noting that a child’s evaluation of his/her performance may be biased by some form of
denial (i.e. the child detects, remembers, correctly appraises the consequences and places them in
the context of the task goal but denies the error occurred, has consequences). Pure denial is rare in
children[11] but is often the explanation for behaviour that might in fact be caused by awareness
deficits [11]. In Beardmore et al. Study [9], emotionally-motivated or defensive denial
(operationalised as a negative/avoidant coping style) was not supported as a contributor to the
child’s poor metacognitve knowledge.
TH E O RY OF AUT O B I O GRAPICAL M E TACOGNITIVE K N O W LEDGE A C Q U I S I T ION BAS E D O N
ON - L INE EXPER I E N C E S
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We hypothesize that metacognitive knowledge is constructed from on-line awareness experiences,
that will progressively allow the child to construct a sense of his/her own cognitive abilities, through
the construction of semantic and autobiographical memories of task performance and difficulties. In
the same way that children’s development of autobiographical memory [66] is related to the
understanding of their own mental states in the past [67][68], we postulate that self-awareness is
related to the memory and understanding of on-line awareness experiences in the past.
Let’s first take the simpler case of an adult. Dirette [69] suggests that awareness of cognitive deficits
develops through “aha” moments, particularly in functional activities (e.g. being aware that one
cannot drive from the actual experience of driving, rather than having been told you cannot drive)
and familiar places (cooking at home rather than in the rehabilitation centre). When an adult is told
that s/he is not able to drive, s/ he may gain some general self-knowledge about his/her driving
capacity, however this will remain a very theoretical knowledge, which we will call “semantic”
metacognitive knowledge (MK). To be truly aware of his/her driving difficulty, s/he needs his/her
own experience of performing poorly in driving, with preserved on-line awareness of making errors
to support self-appraisal of driving capacity. If on-line awareness is intact, it is the actual experience
of being conscious of driving dangerously that will allow him/her to truly internalise knowledge of
his/her driving abilities, make it his/her own, store the “trying to drive” episode in his/her
autobiographical memory and acquire MK that has “autobiographical” characteristics, including the
phenomenological details accompanying the experience of having difficulty on the task (e.g. feeling
anxious, hearing the horns).
Young children acquire most MK from adult reminders and feedback (“put it in your schoolbag or
you’ll forget it”, “you’re very disorganised”). Eventually a child who has been told for years that s/he
is disorganized (like PB in our study), will acknowledge s/he is, gaining some basic semantic
intellectual awareness (or semantic MK), by storing the information “I am very disorganised” in
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his/her semantic memory. However this semantic MK will remain a fact, without a link to an episodic
sense of self.
From a developmental point of view, semantic MK precedes on-line awareness [2]. With age,
children become increasingly conscious of cognitive capacities, strategies for processing information,
and task variables that influence performance [70] and have more attentional resources to devote to
on-line monitoring/error detection. As on-line monitoring skill becomes more efficient, children’s on-
line awareness increases and allows them to be aware of having difficulty with a certain task
(following the steps described in the previous section). Progressively, memories of correctly
appraised performance are stored in memory resulting in increased MK, that does not rely solely on
what the child knows because s/he has been told by his/her parents (basic semantic MK) but on
his/her own experience, with all the phenomenological details accompanying this experience (e.g.
feeling anxious when realising school bag is missing, smelling the burnt cake). Therefore the
memories of these correctly appraised experiences, which the child will truly remember, will allow
full awareness (comprising both semantic and autobiographical components) and will hopefully be
retrieved and used to anticipate future problems (anticipatory awareness) in similar situations (see
figure 4). However, because autobiographical memory matures gradually throughout childhood [66],
a unique experience of failure will probably not be stored or retrieved as clearly as in adults. Children
may recall for example that they enjoyed cooking, and what they managed well, rather than
remembering their difficulties in planning on-task and the strategies they used to overcome
difficulties.
Insert Fig 4 about here
Conversely, for younger children, most MK will be gained from external information and their MK will
essentially rely on the “semantic” awareness (see fig 4). In our view autobiographical MK/intellectual
awareness develops gradually, along with the development of autobiographical memories, and
young children should not be expected to have complete intellectual awareness. However it is worth
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noting that younger children may still exhibit anticipatory awareness, based on their semantic MK:
They may not have lived the experience of being impaired (or developmentally immature) on a task,
but may rely on what their parents taught them (“don’t cross the street on your own”) and on their
semantic general memory (e.g.: children don’t drive cars).
Our theory could explain the dissociation in the MK scores in the discrepancy questionnaire score
and GMT stories. The questionnaire assessed basic knowledge of functioning, which can be qualified
as the “semantic” MK/ intellectual awareness about self and was probably mainly acquired by
repetitive comments of adults (parents, teachers…). Stories on the other hand, especially when they
elicited pertinent examples of personal cognitive failures in the autobiographical memory, relied
more on autobiographic MK/ intellectual awareness, by cueing the children on consequences of the
cognitive failures and phenomenological details developed in the story (how the character felt, what
were the circumstances… ).
FAC T O RS CONTRIB U T ING TO POO R A WARNESS IN C H I LDREN
It is often said that ‘It takes a whole life to know oneself’, reflecting that even for adults, being fully
aware of one’s strengths and weaknesses is challenging. Children with brain injury might have
specific deficits that impact on their functioning, but these are set in the context of (1) having
cognitive functions that are constantly developing, (2) being supported by parents, teachers and
others to carry out new tasks (so not necessarily having the experience of difficulties) and (3) having
limited attentional/executive resources that make monitoring and reflecting on performance difficult
[70]. Thus it might be said that being self-aware is a challenge for everybody, but for children it is
particularly difficult and hence for children with brain injury it is major problem [9].
In our study, children’s awareness was influenced by many factors. For the youngest (IP), a lack of
knowledge about his impairments due to a lack of confrontation probably explained much of his
unawareness. Reassurance and help from parents assured success on tasks but also contributed to
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his lack of awareness. However IP’s emotional responses to failures, suggest that such a non-
confrontational reassurance may not be appropriate, even for children as young as 8. Another factor
is the type of activities children are confronted with: for most children, it appeared obvious that they
would be given help if they attempted to cook a cake and therefore judged the task easy, because
adult help was inherent to the task at their age. For YR, part of his unawareness was probably due to
a denial of his impairment or at least a wish to hide any difficulty.
Awareness is probably easier to gain for some cognitive functions than others, and from our data,
cognitive flexibility seemed to be the most difficult cognitive function to gain awareness of. This was
illustrated by RK who showed excellent awareness on all measures, who frequently talked about his
memory and planning difficulties, but who could not acknowledge his cognitive rigidity.
Questionnaires and stories did not include aspects of cognitive flexibility and it would be a valuable
addition for further development of awareness assessments in both children and adults. For
example, it would be interesting to see whether RK would react to a story where a character shows a
difficulty with cognitive flexibility (such as RK’s own relating to quantity of cooking ingredients).
However being aware of one’s own cognitive rigidity and detecting it on task is, in itself, something
that requires cognitive flexibility; therefore awareness of cognitive flexibility deficit is probably, by
definition, incompatible with such a deficit.
LI M ITATIONS A N D REC OMMENDAT I O N S
It is not possible to determine from our data if the children had more impaired awareness than
healthy children, as we did not include healthy controls with whom to compare awareness scores.
Developmental studies are needed to explore awareness in healthy children, without which
literature lacks a reference to normative standards and degree of awareness impairment in our
clients who suffered a TBI cannot be precisely determined.
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Awareness is multicomponential, and different components have different importance depending on
the child’s age (e.g. autobiographic awareness is not expected before late childhood/adolescence).
Each component should be assessed separately to truly understand where the child’s foundation of
unawareness deficit lies.
Insert Fig 5 about here
Figure 5 summarises the awareness components that are easily measurable separately. Real cooking
seems a feasible, fun and ecologically valid way for studying on-line awareness (please refer also to
figure 3). Prediction and evaluation are important to assess but also to practice and should be
included during activities at school and at home (refer to Ylvisaker [11] for details). For intellectual
awareness, stories seem a particularly well-suited assessment because (1) children find them fun; (2)
children understand them easily; (3) drawings lower working memory demands; (4) consequences
and factors contributing to cognitive failures can be included in the story and elicit awareness of
them. The story format however does not appear to be appropriate for children with severe
reasoning or ToM deficits. Brain storming about personal examples of cognitive failures elicited by
stories (or by another support including questionnaires) allows one to determine whether children
rely on semantic awareness, autobiographical awareness or both for their responses. The
remember/know paradigm and explicit requirement to provide phenomenological details can be
used to differentiate between autobiographical and semantic awareness (see [66][71] for details
about the paradigm referring to autobiographical memory). Assessing anticipatory awareness
remains a challenge but is most likely to be valid during ecological activities at home, school or during
rehabilitation activities using real life settings and activities such as cooking, without prompting and
without explicit knowledge of the child of being assessed.
So far metacognition in children has been mostly explored in meta-memory research. As EF are the
main problem for independent daily living, “meta-EF” studies (and especially “meta-EF” in ecological
settings) are urgently required before engaging children and teams in clinical and research
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programmes of metacognitive strategy training that rely on awareness, which may be recommended
for adults but whose appropriateness for different stages in childhood are not yet established.
DE C L AR ATION O F I N T E RESTS
The authors report no conflicts of interest. This study was supported by scholarships, from the
“SOFMER” (French Society of Physical and Rehabilitation Medicine), the “SFERHE” (French Research
Society against Children’s handicap) and the “Fondation Gueules Cassées”. Results of this work were
presented at the joined 29th SOFMER – 19th ESPRM congress in Marseille in May 2014.
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40. Levine B, Schweizer TA, O’Connor C, Turner G, Gillingham S, Stuss DT, Manly T, Robertson IH.
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in daily life. J Int Neuropsychol Soc. 2010 January [cited 2012 July 27];16:118–129.
43. Miotto EC, Evans JJ, Souza de Lucia MC. Rehabilitation of executive dysfunction: A controlled trial of
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Developmental Neurorehabilitation. 2009 January [cited 2012 July 27];12:76–91.
47. Chevignard MP, Catroppa C, Galvin J, Anderson V. Development and Evaluation of an Ecological Task
to Assess Executive Functioning Post Childhood TBI: The Children’s Cooking Task. Brain Impairment.
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50. Prigatano GP, Altman IM, O’brien KP. Behavioral limitations that traumatic-brain-injured patients
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54. Dennis M, Agostino A, Taylor HG, Bigler ED, Rubin K, Vannatta K, Gerhardt CA, Stancin T, Yeates KO.
Emotional expression and socially modulated emotive communication in children with traumatic
brain injury. J Int Neuropsychol Soc. 2013 January;19:34–43.
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2006 August [cited 2012 July 27];16:397–414.
56. Koriat A, Ackerman R. Metacognition and mindreading: judgments of learning for Self and Other
during self-paced study. Conscious Cogn. 2010 March;19:251–264.
57. Williams D. Theory of own mind in autism Evidence of a specific deficit in self-awareness? Autism.
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58. Stuss DT, Anderson V. The frontal lobes and theory of mind: Developmental concepts from adult
focal lesion research. Brain and Cognition. 2004 June [cited 2014 November 10];55:69–83.
59. Rosenzweig C, Krawec J, Montague M. Metacognitive strategy use of eighth-grade students with and
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60. Hart T, Giovannetti T, Montgomery MW, Schwartz MF. Awareness of errors in naturalistic action
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61. Larson MJ, Fair JE, Farrer TJ, Perlstein WM. Predictors of performance monitoring abilities following
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62. Larson MJ, Perlstein WM. Awareness of deficits and error processing after traumatic brain injury.
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64. Yochim BP, Baldo JV, Kane KD, Delis DC. D-KEFS Tower Test performance in patients with lateral
prefrontal cortex lesions: the importance of error monitoring. J Clin Exp Neuropsychol. 2009
August;31:658–663.
65. Ownsworth T, Fleming J, Tate R, Shum DH, Griffin J, Schmidt J, Lane-Brown A, Kendall M, Chevignard
M. Comparison of error-based and errorless learning for people with severe traumatic brain injury:
study protocol for a randomized control trial. Trials. 2013 [cited 2014 April 29];14:369.
66. Piolino P, Hisland M, Ruffeveille I, Matuszewski V, Jambaqué I, Eustache F. Do school-age children
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67. Nelson K, Fivush R. The Emergence of Autobiographical Memory: A Social Cultural Developmental
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68. Perner J, Dienes Z. Developmental aspects of consciousness: how much theory of mind do you need
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69. Dirette D. The development of awareness and the use of compensatory strategies for cognitive
deficits. Brain Injury. 2002 January [cited 2012 August 23];16:861–871.
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70. Bjorklund DF. Children’s Thinking: Cognitive Development and Individual Differences. Cengage
Learning; 2011.
71. Piolino P, Desgranges B, Manning L, North P, Jokic C, Eustache F. Autobiographical memory, the
sense of recollection and executive functions after severe traumatic brain injury. Cortex. 2007
February;43:176–195.
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Figure 1: Correspondence between Crosson’s and Toglia and Kirk’s model and Developmental psychology
terminology
254x190mm (96 x 96 DPI)
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YR PB CS RK IP
Sex Boy Girl Girl Boy Boy
Age at inclusion (years) 14 11 11 13 8
Medical history
Age at injury (years) 2.5 2.5 6.5 7 5.5
Initial GCS
<7
6
4
3
6
Brain imaging Unknown
Large right hemisphere
hemorrhage and edema,
right parietal depression
fracture
Cerebellar and right parieto-
occipital lesion with
depression fracture
Subdural hematoma with
diffuse edema and
pneumocephalus
Brain stem hemorrhage,
Diffuse subarachnoid
hemorrhage
Duration of coma (days)
Unknown
Unknown
1
10
6
Associated impairments,
reported in medical records
and previous assessments
Severe behavioral
disorders
Epilepsy absences treated by
carbamazepine
FSIQ 69. Impaired ToM and
language pragmatics
Spastic equinus foot
Attention problems
Left arm weakness
ADHD
Glasgow Outcome Scale 3 (severe) 2 (moderate) 3 (severe) 3 (severe) 2 (moderate)
Neuropsychological assessment
WISC IV matrices 11 9 7 16 11
WISC IV vocabulary 6 9 5 7 12
BADS-C 6 part test 7 10 7 8 6
CMS stories - immediate 9 8 8 4 8
CMS stories- delayed 8 5 7 4 9
CMS backward span Missing data 8 8 10 18
CMS words list - immediate Missing data 9 12 12 14
CMS words list - delayed Missing data 13 7 16 16
Parents BRIEF T-score: BRI 63 71 87 95 57
Parents BRIEF T-score: MI 68 82 76 79 56
Parents BRIEF T-score: GEC 68 80 82 88 57
Parents DEX-C : Z score 3,53 4,7 3,7 5,1 0,7
CCT: Z-score Scoring impossible
due to complete
failure on task
4,8 2,2 7,1 18,0
Effect of Intervention (Context-sensitive pediatric Goal Management Training)
Dropped out
Improved on EF
questionnaires. No effect on
cooking task.
Improved on EF
questionnaires. No effect on
cooking task.
Improved on EF
questionnaires and
cooking task.
Adequate application of
strategies on complex tasks,
improved on cooking task, no
effect on EF questionnaires
Table 1: Demographic, medical and neuropsychological characteristics of the participants
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Note: GCS: Glasgow Coma Scale score; ToM: Theory of Mind; FSIQ: Full Scale Intellectual Quotient; ADHD: Attention Deficit – Hyperactivity Disorder; WISC [1]:
Wechsler Intelligence Scale for Children; BADS-C: Behavioural Assessment of the Dysexecutive Syndrome for Children; CMS[2]: Children’s Memory Scale; BRIEF [3]
,
[4]: Behavior Rating Inventory of Executive Functions; BRI: Behavioral Regulation Index; MI: Metacognition Index; GEC: Global Executive Composite Score. DEX-C [5]:
Dysexecutive questionnaire for children. CCT [6]
,
[7]: Children’s Cooking Task. Neuropsychological test results are reported as standard scores, unless otherwise stated. For
the CCT and for executive functions questionnaires, BRIEF and DEX-C, a higher score indicates greater impairment. The clinical cut-off score for the BRIEF is set at a T-
score of 65. Paper and pencil tests of executive functions (EF) [8] and detailed effect of intervention are reported elsewhere; all children had at least two out of three EF
tests indicating impairment relative to controls (< 2SD below controls’ scores)[9].
References of tests used:
1. Wechsler D. WISC-IV: échelle d’intelligence de Wechsler pour enfants : manuel d’interprétation. ECPA - Les Ed. du Centre de psychologie appliquée; 2005.
2. Cohen M. Echelle de Mémoire pour Enfants. Les éditions du centre de psychologie appliquée.; 2001.
3. Gioia GA, Isquith PK, Guy SC, Kenworthy L. Behavior Rating Inventory of Executive Function® (BRIEF®). 2000.
4. Gioia GA, Isquith PK, Guy SC, Kenworthy L. Behavior Rating Inventory of Executive Function® (BRIEF®). Adaptation française A. Roy, N. Fournet, D. Legall, J-L
Roulin. Hogrefe; 2000.
5. Emslie H. Behavioural Assessment of the Dysexecutive Syndrome for Children: (BADS-C). Thames Valley Test Company; 2003.
6. Chevignard MP, Catroppa C, Galvin J, Anderson V. Development and Evaluation of an Ecological Task to Assess Executive Functioning Post Childhood TBI: The
Children’s Cooking Task. Brain Impair. 2010;11:125–143.
7. Chevignard MP, Servant V, Mariller A, Abada G, Pradat-Diehl P, Laurent-Vannier A. Assessment of executive functioning in children after TBI with a naturalistic open-
ended task: A pilot study. Dev Neurorehabilitation. 2009 January [cited 2012 July 27];12:76–91.
8. Roy A, Roulin J-L, Le Gall D, Fournier N, Groupe FEE. Fonctions Exécutives chez l’Enfant. unpublished
9. Krasny-Pacini A, Limond J, Evans J, Hiebel J, Bendjelida K, Chevignard M. Context-Sensitive Goal Management Training for Everyday Executive Dysfunction in Children
After Severe Traumatic Brain Injury. J Head Trauma Rehabil. 2014 February 3.
.
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Anosognosia/Awareness deficit scores for each type of awareness
254x190mm (96 x 96 DPI)
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Figure 3: On-line awareness steps required to arrive at an adequate post-task evaluation
254x190mm (96 x 96 DPI)
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Figure 4: Autobiographical awareness mediated by on-line experience model.
We hypothesise that the relative importance of different inputs varies with developmental age.
254x190mm (96 x 96 DPI)
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Figure 5: Proposed framework for awareness assessment
254x190mm (96 x 96 DPI)
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Appendix 1: Adapted Goal Management Training questionnaire for children
Does it happen to you…
•
Walking into a room and forgetting what it was that you had come for?
• Finding that you don’t have time to stop and think?
• Forgetting something that needed to be done at a certain time (e.g. calling someone, taking
your medication, go to your sports lesson, a TV programme that you wanted to watch)?
• Making a mistake because you weren’t thinking about what you were doing at the time?
• Not remembering where you had got to in a task/ an exercise at school
?
• Spending too long searching for things (e.g. school bag, keys, shoes) because you don’t
remember where you put them?
• Finding that you have done things in the wrong order?
• Feeling that others expect too much from you?
•
Losing track of time?
• Running out of time because you got too caught up in something that you were doing (e.g.
spending time tidying your desk at school and not finishing a test on time)?
•
Having difficulty making decisions?
•
Daydreaming rather than thinking about what you were doing?
• Having problems organizing your time (e.g. arranging in which order to do your homework,
not finishing a test on time, not giving yourself enough time to get somewhere, being late)?
• Keeping making the same mistakes (e.g. when using a computer, doing a math exercise at
school or building a construction)?
• Having to go back to get something that you had forgotten to take with you?
• Not thinking something through before acting?
• Starting an exercise and realising once you’ve started that are not doing what was asked?
• Avoiding thinking about a problem because it just seems too complicated?
• Do sometimes feel that you don’t know where to begin in order to carry out a task (a school
assignment, a construction, homework…)?
• Does it happen that you read the instructions at school too quickly and fail the exercise because of
that?
• Do you manage to estimate how long a task will take you before starting it? (e.g.: tidying your room,
going to a friend’s house to fetch school work, solving a math exercise)
• Do you manage to estimate how difficult an exercise is before starting it?
• Do you sometimes feel that things go too quickly for you and that you don’t manage to keep up?
•
Do you sometimes
find that you haven’t been listening to important information that your teacher or
parents were telling you?
• Is it difficult for you to think about, or to do two things at the same time?
• Do you manage to prepare your school bag alone without forgetting anything?
• Do you sometimes forget if you have done something (ex: feeding your pet, closing the entrance
door, finishing your homework)?
• Do you sometimes forget important things you had to do and do something else instead? (e.g: go on
the computer for 10 minutes and find out one hour later that you forgot to do your homework)
• Do you sometimes feel there are too many things, too much information in your head and that you
don’t manage to deal with them?
• Do you sometimes find that your brain wanders away from what you are doing?
• Do you sometimes feel that you know how to carry out an exercise or a task, but once you’re doing
it, things get mixed up in your head?
This is a translation of the French questionnaire used in the study
38
. All items relate to the content of
the intervention (Context-sensitive Goal Management Training), that focused on improving executive
functions and prospective memory. The questionnaire has not been validated and needs further
adaptations if used outside the context of the intervention.
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Error detected?
Error remembered?
Implications/
Consequences of
the error being
evaluated
correctly?
Error incorporated
into the general
appraisal of the task
success/ goal
attainment?
Recognition of
common thread in
this task and other
tasks where the same
type of error may
occur?
Awareness:
experience and
memory of having
made an error, that
had consequences,
and compromised
overall task success,
and that may reoccur
in a similar situation.
No awareness that
difficulties
experienced can
reoccur in a similar
situation
(generalization)
Disconnection
between the error
and global
appreciation of the
ability to perform the
task
Error underestimated
or denied because not
perceived as being
important
No memory of having
performed the task
poorly
No experience of
having performed
poorly
On-line
verbalisations/
behaviour
Have you met your
goal?
How have you done
overall in this task?
Do you think that
error mattered?
What are the
consequences of
forgetting the sugar ?
Can you tell me which
errors you’ve made?
(spontaneous)
Do you remember that
you …….… (prompted)?
Oops! I
forgot to
mix the
pastry!
Well my chocolate
omelet has an
interesting taste… oh
but that wasn’t the
goal of the task, I was
supposed to make a
chocolate cake!
I must be more
careful tonight when I
make crepes for my
Dad, as I may make
the same mistake and
miss one of the steps
in the recipe!
Oh no! I forgot
the sugar! The
cake will taste
horrible!
My cake looks flat...
Oh no! I remember
what I’ve done: I
forgot the baking
powder!
Do you think you might
make the same kind of
error in another activity?
Can you give me an
example?
Figure 3: On-line awareness steps
required to arrive at an adequate
post-task evaluation
Possible assessment/questions to ask a child after the task to evaluate which steps are missing for gaining awareness
