Pictorial Interview of Children’s Metacognition and Executive Functions (PIC–ME): A Comparison Between Children With and Without Attention Deficit Hyperactivity Disorder

PURPOSE: Executive functions (EF) are higher-level self-regulatory constructs involved in complex and novel activities. There is strong evidence that EF deficits (EFD) are typical among children with attention deficit hyperactivity disorder (ADHD) and that EFD negatively impact their occupational performance (Chiang & Gau, 2014). The ability to identify children’s EFD is central for collaborative goal setting used in occupational therapy practice.

The literature is inconclusive regarding young children’s ability to identify challenges and set goals. Studies on self-perception of children with ADHD have documented strong evidence for overestimation of competence, termed positive illusory bias (PIB), in various domains (Steward, Tan, Delgaty, Gonzales, & Bunner, 2014). PIB in ADHD has been attributed to psychological-protective and neurocognitive mechanisms. However, it is possible that given appropriate accommodations addressing both psychological and cognitive barriers to the assessment procedure, children with ADHD will be enabled to participate in identifying their strengths and at least some of their EF challenges and harness them into the goal-setting process.

Therefore, the Pictorial Interview of Children’s Metacognition and Executive Functions (PIC–ME) was designed to evaluate the self-perception of EFD among young children (ages 5–10 yr) with ADHD in occupational contexts. The overarching aim of this study was to examine the initial reliability and validity of the PIC–ME assessment designed to enable children to access self-knowledge using nonthreatening pictorial portrayals of common EF challenges that children encounter in daily life. Specific questions were as follows: (1) What is the internal reliability of PIC–ME EF scales and total score? (2) What is the correlation between parent PIC–ME scores and an established ecological EF measure? (3) Is there a difference between groups with and without ADHD on parent and child PIC–ME scores? (4) How many items on average are identified by children with ADHD for goal setting?

DESIGN: This study used a descriptive design. Participants included children with ADHD (n = 100) ages 5–10 yr referred for Cognitive–Functional (Cog–Fun) treatment and 44 control participants who were typically developing children from a convenience sample matched for age and gender. The inclusion criterion for the study group was medical diagnosis of ADHD, and the Conners’ Parent Rating Scale–Revised (CPRS–R; Conners, 2000) score of ≤65 was used to provide a baseline level of severity of symptoms. Exclusion criteria were serious psychiatric or neurological disorder or special education setting. For the control group, ADHD was excluded based on CPRS–R score ≥65. Ethical approval was obtained from the institutional review board, and parents signed informed consent while children provided assent.

METHOD: Children were individually administered the PIC–ME, while parents completed a parent version of the PIC–ME and the Behavior Rating Inventory of Executive Function (BRIEF) questionnaire. Data were analyzed with IBM SPSS Statistics Version 19. Since PIC–ME variables did not meet criteria for normal distribution, data were analyzed with nonparametric statistics. Spearman correlation analysis was used to examine relationships between variables, and the Mann–Whitney U test was used to compare scores between groups. Frequencies were calculated for the goal scale in the ADHD group.

RESULTS: Analyses of group characteristics demonstrated no significant differences between groups on age (ADHD group, M = 7.96, SD = 1.06; control group, M = 7.73, SD = 1.33; t = –1.11, p = .266) or gender (ADHD group, 64% male; control group, 50% male; p = .115). As expected, the mean BRIEF Global Executive Composite (GEC) scores were significantly higher for the ADHD group (M = 67.13, SD = 9.53) than the control group (M = 42.14, SD = 6.49; p = .000), pointing to more impaired EF in the ADHD group.

The results for internal reliability demonstrated excellent reliability for the total EF score for both child and parent ratings (Cronbach’s α = .953 and .914, respectively). Reliability results for EF scales were in the acceptable range for most of the parent ratings (α = .767–.871), except for the Effort scale (α = .641), yet they were lower and questionable for most of the child ratings (α = .541–.775). Concurrent validity analysis revealed a high correlation between the total EF PIC–ME parent score with the BRIEF GEC score (r = .724, p < .000). Construct validity analyses revealed significant between-group differences on parent ratings of all PIC–ME scales except for the Strengths scale. An opposite trend was found for child ratings, whereby no significant between-group differences were found on all PIC–ME scales except for the Strengths scale. Descriptive analysis of the goal scale revealed an average of 10 items (SD = 8.58) that children wanted to change. All EF items were identified by at least 10% of the children as treatment goals.

CONCLUSION: Results support initial reliability and validity for the PIC–ME. Although children with ADHD are not completely aware of their EF profile, they demonstrate partial awareness of approximately 50% of their challenges and are able to participate in goal setting. Further research is required to substantiate these findings.

References

Chiang, H. L., & Gau, S. S. (2014). Impact of executive functions on school and peer functions in youths with ADHD. Research in Developmental Disabilities, 35, 963–972. https://doi.org/10.1016/j.ridd.2014.02.010

Conners, C. K. (2000). Conners’ Rating Scales–Revised technical manual. North Tonawanda, NY: Multi Health Systems.

Steward, K. A., Tan, A., Delgaty, L., Gonzales, M. M., & Bunner, M. (2014). Self-awareness of executive functioning deficits in adolescents with ADHD. Journal of Attention Disorders, 21, 316–322. https://doi.org/10.1177/1087054714530782