Empowering Pre-Adolescents with ABI through Metacognition: Preliminary Results of a Randomized Clinical Trial


Lucia Willadino Braga, Luciana Rossi, Ana Luisa Lourenco Morettoa, Juliana Magalhaes da Silva, Michael Cole

The SARAH Network of Neurorehabilitation Hospitals created the family-based methodology for children with acquired brain injury (ABI) over time.  Throughout the years, this methodology has evolved with ongoing research and clinical experience, adjusting to the changing needs of the child and family [1-8,28]. A randomized clinical trial showed that children with ABI rehabilitated with the participation of the family within the context of everyday routines had better cognitive and motor outcomes after one year of intervention than the children treated exclusively by professionals [7]. However, the role of the family in the development and daily life of the child starts to change in preadolescence, when friends become increasingly important.

The beginning of adolescence is marked by extensive social and emotional changes that impact the individual's relationship with family and friends, resulting in distinct challenges [12,15,21] . This phase is characterized by the acquisition of new cognitive, logical and hypothesis-forming abilities. There is greater interest in social relationships organized in peer groups. The combination of developmental changes leads to new ways of interacting with the parents; furthermore, preadolescents begin to spend twice as much extracurricular time with their peers than with their families [21]. Adolescents and young adults with ABI can have various problems caused by impulsiveness, aggression, social awkwardness and impaired social perception [29]. It is especially important, then, to develop an approach aimed at empowering them with self-regulating abilities before they mature into full adolescence.

To help preadolescents with ABI, we made several changes to the family-based methodology to create a new intervention approach more tailored to the specific needs of this stage of development and to prepare them for adolescence and the start of adult life. The new project centers on developing cooperative learning for preadolescents with ABI, with a strong emphasis on community and peer relationships [9]. The initial foundation for this approach was based on concepts from the 5th Dimension (5D) [10-11].

The project that we created for preadolescents with ABI used some of the 5thD concepts, which were adapted to meet the special needs and challenges of this population. The new project is called Metacognitive Dimension (MCD) and aims to enrich and stimulate the social, academic, intellectual, and neuropsychological development of preadolescents with ABI, empowering them through executive functions and metacognition. Metacognition describes individuals’ ability to track their cognitive processing and comprises both knowledge and experience; it can lead to learning self-regulation and other cognitive functions [27].

The involvement of college undergraduates in the project is fundamental to stimulating metacognition, because it permits the participants to work in pairs. These are students majoring in psychology. They are taught the basic concepts of mediation, metacognition and learning, and are supervised in their MCD activities by qualified professionals from the SARAH rehabilitation center’s multidisciplinary team. These students are important; because of their age and experience, they share a similar vocabulary and range of interests with the preadolescents in the project. Students just starting college are particularly appropriate “more capable peers”, as per Vygotsky’s concept: they are closer in age to the preadolescents and consequently better satisfy the “more capable peer” requirement than older students, who might instead identify with the parents or professional staff.  

The students are instructed in how to deploy the concept of cooperative learning, which refers to instructional methods in which pairs or small groups collaborate to accomplish a shared goal [19,24]. The aim of this cooperation is for individuals to maximize their own and each other’s learning, with members striving for joint benefit [20]. Interactions with the students stimulate a variety of cognitive and social functions including metacognition, thereby helping the preadolescents reflect on their thought processes and behavior.

To test the hypotheses that the MCD intervention is better at promoting self-esteem and the development of metacognition than the traditional approach to preadolescents with ABI, we conducted a randomized clinical trial comparing the groups.


Participants were 29 preadolescents with ABI in treatment at the SARAH Network of Neurorehabilitation Hospitals in Brazil, with an average time of 5.3 years since the injury. At recruitment the preadolescents were attending school and involved in longitudinal follow-up by the rehabilitation team, within the family based approach. Inclusion criteria were: (1) ages between 9 and 13 years old; (2) history of moderate or severe ABI on the Glasgow Coma Scale (GCS) [18]; (3) ABI onset at least 12 months prior to study (i.e., chronic stage); (4) Scores in 2 Broader Indexes of the Behavior Rating Inventory of Executive Function (BRIEF)[16]: T Score of the Behavioral Regulation Index ≥ 50 and t Score of the Metacognition Index ≥ 50. Exclusion criteria were: (1) relevant sensorial disorders; (2) unresponsive state; (3) serious neuropsychiatric diagnosis; (4) motor or neuropsychological impairments that preclude assessment tests.

From October 2010 through February 2011, 45 patients were considered; 29 fulfilled the inclusion criteria and were followed up from February to April 2011. Subjects were randomly assigned to either the MCD intervention program (n=14) or to a control group (n=15). The groups were homogenous; there was no difference in any of the characteristics, thereby confirming the effectiveness of the randomization (Table I). 

Table I. Characteristics of participants*




Gender (female/male)   5/9 3/12
Age at start of study (years) 10.3 (2.1)  10.5 (1.8)
Age at brain injury onset (years) 4.8 (3.0) 5.4 (2.4)
Time lapsed since brain injury (years) 5.5 (3.3) 5.1 (2.4)
Family’s average monthly income (dollars) 789 (353) 865 (397)
Glasgow score at brain injury onset 9.4 (3.4) 9.1 (2.7)
BRIEF: Behavioral Regulation Index 65.2 (12.8) 58.3 (9.5)
BRIEF: Metacognition Index  64.9 (9.1 59.8 (9.9)
Motor impairment, n
       None 7 10
       Monoparesis  3 1
       Hemiparesis   3 3
       Tetraparesis     1 1

Unless otherwise stated, the values are means and standard deviations (SD); n – number of child. 
* There are no significant differences between groups.

A majority (83%) had MRIs done on a 3.0 Tesla scanner (Magnetom Trio, Siemens). Several preadolescents (17%) were unable to submit to an MRI due to behavioral problems; in these cases, CT scans (Mx8000, Multislice CT Imaging System, Phillips) were conducted. The most frequent traumatic injuries affected the frontal region of the brain, followed by the temporal area and corpus callosum. There was no significant difference in lesion between the groups (Table II).

Table II. Neuroimaging evaluation: frequency of children with lesions in each given location, by treatment groups*


n (%)

n (%)

Right 5 (36) 4 (27)
Left 4(29) 5(33)
Occipital 2 (14) 3 (20)
Right 3(21) 4(27)
Left 1 (7) 2 (13)
Right 1 (7) 1 (7)
Left 1 (7) 2 (13)
Brainstem   1 (7) 1 (7)
Cerebellum 3(21) 4(27)
Corpus callosum 4(29) 5(33)
Basal nuclei
Right 2(14) 1(7)
Left 1(7) 2(13)

n – number of child; % – percentage relative to the number of participants in the study group.
* There are no significant differences between groups.
Note: subject may present lesion in more then one location.


Intervention group

The preadolescents of the experimental group participated in the Metacognitive Dimension (MCD) program. In this case, college students majoring in psychology or teaching acted as the more capable peers. The students deployed deliberate mediational strategies to foster the preadolescent’s neuropsychological development and metacognition.

The preadolescents in this group came to the center 2 afternoons a week and participated in the playworld activities mediated by the college students and rehabilitation team. They engaged in these activities for two hours every visit. There were a total of 26 sessions over a three-month period.

At the end of each afternoon’s activities, the students and professionals gathered to discuss clinical aspects and exchanges, propose ideas, and make suggestions for the project. In addition, the rehabilitation team prompted the students to theoretical and practical reflections by leading the discussions and encouraging them to engage their growing knowledge and observations.

Control group

The preadolescents in this group continued to be treated according to the guidelines of the family-based approach, and underwent individual periodic reviews with the multidisciplinary team at the rehabilitation center [7-8].


After 3 months of intervention, the preadolescents in both groups were evaluated. Each outcome was analyzed according to the intention-to-treat principle.
The two primary outcome measures were 1) Self-Concept Scale for Children (SCSC)[23]; and 2) Evaluation Scale of Elementary School Learning Strategies (ESESLS)[22] that assessed the metacognitive learning strategies. Both scales were standardized on the Brazilian population.

Before starting the study, the parents answered the Behavioral Rating Inventory of Executive Functions (BRIEF) questionnaire, used to evaluate executive function and behavior in the home environment, as well as inclusion criteria. After 3 months of intervention, this questionnaire was given to the parents again as secondary outcomes.  

Data Analysis

Fisher's Exact and Mann-Whitney tests were used to check differences between the groups at baseline. The Mann-Whitney also analyzed the primary outcomes (metacognition - SCSC and ESESLS) obtained only after the intervention period, taking our hypothesis into account. The unique variable measured before and after the intervention was the BRIEF questionnaire, considered exclusion criteria at baseline and as secondary outcomes at the end of the study. Statistical significance for these analyses was P<0.05.


There were significant differences between the experimental and control groups on the Self-Concept Scale for Children (SCSC) and the Evaluation Scale of Elementary School Learning Strategies (ESESLS). After 3 months, the experimental group presented higher averages than the control group in both the SCSC and ESESLS.

The preadolescents in the experimental group obtained an average 58-point overall score on the SCSC scale (Table III), significantly better than the control group’s average of 42 points (p=0.043). In all of the SCSC sub items, the experimental group had a point average superior to the control group, with statistical significance in the academic self-concept (p=0.009) and family self-concept (p=0.029) sub items.

Table III. Self-Concept Scale for Children (SCSC)


mean (sd)

mean (sd)

Self-Concept Scale for Children  58 (18.8)  42 (20.4)  0.043
Personal self-concept 62 (16.5) 45 (23.5) 0.055
Academic self-concep 60 (19.2) 38 (18.6) 0.009
Family self-concept  61 (19.3) 43 (17.6)  0.029
Social self-concept 50 (22.8) 42 (22.5) 0.314

sd - standard deviation. 
* Mann-Whitney.

On the ESESLS scale (Table IV), the experimental group obtained an average 52 points, while the control group had a significantly inferior average of 29 points (p=0.033). In the ESESLS sub items, the experimental group always had better performance, with a significant difference between the groups in the sub items “absence of dysfunctional strategies” (p=0.003) and “metacognitive strategies” (p=0.003).  

Table IV. Evaluation Scale of Elementary School Learning Strategies (ESESLS)


mean (sd)

mean (sd)

Primary outcomes: by overall score and by domain
Evaluation Scale of Elementary School Learning Strategies 52 (28.4) 29 (28.5) 0..33
Absence of dysfunctional strategies 58 (27.6) 27 (23.9)


Cognitive strategies 39 (26.9) 34 (22.6) 0.660
Metacognitive strategies 56 (29.9) 25 (20.0) 0.003

sd - standard deviation. 
* Mann-Whitney.

BRIEF was used to compare the differences between the parents’ rating in the two groups, pre and post-intervention. No differences between the groups were observed. However, the experimental group had better scores (which in the BRIEF were expressed by a reduction in the T score), on the Global Executive Composite and on the 2 Broader Index, Behavioral Regulation Index and Metacognition Index. In the domains Shift, Emotional Control, Initiate, Working Memory, and Plan/Organize, the experimental group also obtained greater improvement in parental ratings but, possibly because of the small sample size, these differences were not significant (Table V).

Table V. BRIEF results (T score): improvement in three months (second evaluation minus first evaluation)*

BRIEF DomainsGroups

mean (sd)

mean (sd)

Behavioral Regulation Index  -1.1 (7.5) 4.1 (12.4)
Inhibit 0.1(11.3) -1.3(10.0)
Shift -1.3 (9.9) 3.7 (14.2)
Emotional Control -2.4 (8.1) 2.2 (12.3)
Metacognition Index -0.3 (8.9) 2.2 (7.6)
Initiate -3.3 (12.5) 2.9 (6.7)
Working Memory -1.4 (5.3) 2.0 (8.3)
Plan/Organize -1.3 (8.4) 3.1 (10.7)
Org of Materials 3.7 (15.3) 1.5 (10.4)
Monitor 1.4 (11.8) 2.1 (11.7)
Global Executive Composite -1.5 (7.9) 3.0 (7.4)

sd - standard deviation. 
* There are no significant differences between groups.


We decided to conduct this randomized clinical trial because there was no previously published evidence that an intervention program based on social mediation, cooperative learning and metacognition (Metacognitive Dimension) can help preadolescents with ABI improve their cognitive strategies and self-concept. After only three months, the group that participated in the intervention program presented more gains than the control group in metacognitive strategies (planning, monitoring and regulating behavior) and absence of dysfunctional strategies (use of strategies not very effective for the given setting or situation), as assessed by the Evaluation Scale of Elementary School Learning Strategies (ESESLS).  Cooperative learning, used in MCD, is based on peer interactions aimed at collaborative learning in social settings [19-20,24-25]. Student mediation, even if for a relatively short period of time, allowed the preadolescents with ABI to develop metacognitive strategies. They learned to think about their own thought processes and behavior, which facilitated self-regulation and self-control, and improved social relationships.

As noted by Ylvisaker and Feeney [26-27], better metacognition in a child with ABI fosters improvement in other cognitive functions as well as self-regulation. Self-concept (measured by SCSC) is a fundamental aspect of preadolescent development; it helps improve learning [13,17]. There appears to be a correlation between metacognition and self-concept.

We are currently working on another study that is being developed with the experimental (MCD) and control groups, in which we analyze the qualitative data of the Metacognitive Dimension program. For that study, interviews with these preadolescents are being conducted using open-ended questions 3 months post-intervention, and the results are currently undergoing analysis.  In most rehabilitation programs, preadolescents with ABI are seen by qualified rehabilitation professionals who focus on specific disorders (e.g., behavior, learning, communication, etc.) that are observable throughout the course of development. The MCD approach offers the possibility of improving aspects, such as self-esteem and metacognition, which generalize to other situations, such as daily life and social relationships. In addition to the results obtained with the preadolescents with chronic ABI, we also observed, with the MCD program, that the integration of the college students was very productive. The students optimized the rehabilitation team’s work, increasing the number of patients that could be treated by a smaller team of professionals while, at the same time, giving the young students, tomorrow’s practitioners, an opportunity to experience theories in practice under supervision and, consequently, improving their learning process. The participation of students obviously reduces the costs of the intervention, but most importantly, they are capable of doing more than the multidisciplinary team if they are well supervised, because they have the vocabulary and interests that allow them to become more experienced peers in this type of approach.

The preliminary results of this study suggest the hypothesis that an intervention capable of stimulating metacognition and self-regulation during preadolescence can help prevent future problems in social behavior in later adolescence and young adulthood. In the concept of “latent injury” in ABI [14], these preadolescents require longitudinal follow-up. We will expand the sample and continue the randomized controlled trial to verify the consistency of these initial data. If confirmed, this methodology can be implemented at other institutions that treat preadolescents with ABI.  The possibility of working with students, which means, in effect, working with peers, appears to be a more ecological practice during this stage in life because adolescents spend more than double their time with their peers than they do with their own families.


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Lucia Willadino Bragaa*, Luciana Rossia, Ana Luisa Lourenco Morettoaa, Juliana Magalhaes da Silvaa, Michael Coleb

a SARAH Network of Neurorehabilitation Hospitals SMHS Q.501 – Cj.A – Térreo - Diretoria 70.335-901 – Brasília – DF - Brazil

b University of California at San Diego (UCSD) Department of Cognitive Sciences, 515 9500 Gilman Drive 92093-0515 LA JOLLA – CA – USA

*Corresponding author