By Avgerinou Konstantina Occupational Therapist, University of Thessaly, Neurorehabilitation

Introduction and why I chose this topic?

My name is Konstantina Avgerinou, and I have been working as a Pediatric Occupational Therapist for the past four years. As a Postgraduate student in Neurorehabilitation at the Department of Medicine of the University of Thessaly in Greece, we were introduced to the concept of "metacognition" during our coursework, specifically in discussions regarding how "knowledge" influences motor rehabilitation. The discussion then turned towards how widespread this concept was among fellow Greek therapists occupational therapists and others and it became clear that there was a gap, both in research and in literature, regarding what we know about metacognition and how it is linked to movement, especially with adults. Moreover, our knowledge seems to be even more limited when it comes to pediatric populations.

Literature review

In this context, and inspired by the organization of the 8th Panhellenic Occupational Therapy Congress, I decided to conduct a literature review with the aim of presenting it to my colleagues in order to update them on recent insights regarding the application of metacognition (as a concept). Below, you will find an outline of the results and discussion of my findings.

What search methodology was used?

A literature search was conducted using PubMed, Google Schoolar, and the Cochrane Library, focusing on keywords related to metacognition, cerebral palsy, and occupational therapy. Due to the limited research available on occupational therapy intervention targeting metacognition in children with cerebral palsy, combinations of keywords were used to generate more specialized and relevant search results. Οnly 5 of the initial 75 articles were able to be included, those which involved  children or adolescents with CP, having an intervention implemented by occupational therapist and the results of each intervention to be related to direct or indirect effects on movement.

What were the results?

• What were the inclusion criteria and measures used in the included studies?

The reviewed studies standardized criteria for inclusion and evaluation. Most applied the Gross Motor Function Classification System (GMFCS), and Manual Ability Classification System (MACS) for motor classification, where one study also used the Kaufman Brief Intelligence Test 2 (KBIT-2). Goal setting was primarily conducted with the Canadian Occupational Performance Measure (COPM) , sometimes alongside the Goal Attainment Scale (GAS) and Perceived Efficacy and Goal Setting System (PEGS) . Outcome measurement consistently included the COPM, supplemented by the GAS,  Activity Scale for Kids (ASK) , and specific motor tests such as the Box and Block Test and Bruininks-Oseretsky Test of Motor Proficiency Measure (BOTMP) , with additional tools for range of motion and fine motor assessment when relevant.

• Results and insights from the reviewed studies

• In the initial 75 articles that were scanned, were found growing interest in enhancing metacognitive skills in children with cerebral palsy, though most studies targeted organizational and learning strategies to improve academic performance rather than functional goals. Few studies were authored by occupational therapists, and the predominant intervention used was the Cognitive Orientation to daily Occupational Performance approach (CO-OP), applied in five studies.
• All included studies involved children diagnosed with cerebral palsy, though two also had small groups with spina bifida or traumatic brain injury, with cerebral palsy being the majority in both. The participants’ ages ranged from 7 to 15 years, consistent with evidence that data on metacognitive processes are more reliable from age seven and above.
• The findings of the research offered important evidence on how the CO-OP intervention can support improvements in task performance by making use of metacognition. Specifically, the studies reported outcomes related to:

• Transfer of occupational performance results over time,
• Transfer of the metacognitive global strategy to untrained tasks
• Increased self-perception and awareness of personal goals supported by one’s metacognitive skills
• Higher occupational performance achievement of targeted (trained) goals
• Greater self-confidence in managing novel or untrained situations because of awareness of one’s metacognitive skills
• Improvement in motor skills through self monitoring
• Enhancement of executive functions especially planning focus and organization support by the metacognitive global strategy

Points to consider: Discussion of the results

Based on the results of the search, occupational therapists appear to have chosen the CO-OP approach to work on the occupational performance of the children with cerebral palsy and to enhance their metacognition. Further analysis of the findings indicated that this intervention benefits the participating children not only within the time frame of the research but also in the long term.

• Meta cognition and generalization & transfer

The CO-OP intervention is recognized as a metacognitive approach because it goes beyond teaching specific skills, enabling children to internalize and understand the broader learning process. This involves transferring and generalizing skills to new goals, even in unstructured learning contexts. Through mechanisms like self-monitoring and self-control, children learn either new motor skills or improve underdeveloped ones by actively exploring different strategies. By reflecting on and adapting their actions based on past experiences, they can identify the most effective solutions to motor challenges and enhance overall performance.

• Clarifying key terms

A recurring issue in the search process was the overlap and confusion between the concepts of “metacognition” and “executive functions’. “Metacognition” was often interchanged for “cognitive strategies,” and sometimes labeled as “executive functions.” According to AOTA, executive functions are classified separately from metacognition, under higher cognitive functions within specific mental functions.

• Participants heterogenity in diagnosis

The 5 reviewed studies mainly involved children with cerebral palsy but also included participants with other conditions, such as spine bifida and traumatic injuries. Despite this diagnostic heterogeneity, all participants were analyzed as a single group, and the distinct effects of each condition’s pathophysiology were not examined.

What suggestions can guide the application of metacognition in children with cerebral palsy?

In order to continue and deepen the field under study, it is important to conduct further research on the CP population regarding the application of metacognitive strategies in the motor domain. In the majority of existing interventions, motor difficulties are worked on by focusing on skill and the passive involvement of the individual, while the motor cognitive strategy under study tends to integrate the individual in goal setting and planning.

Since, as mentioned by the characteristics of the research studies, the children were not in the same plethora, it would be useful to take into account the strengths and weaknesses of children from higher levels in the MACS & the GMFCS, in order to draw conclusions regarding the application or not of the relevant methods, as it is possible that continuous monitoring and control cannot be applied.

Limitations of the study

The initial search of articles shows interest in metacognition, the participants goals though are mainly in the area of organizational skills rather than movement-related skills. While CO-OP was the  only approach that met the inclusion criteria, its findings demonstrated effectiveness in achieving motor goals and supporting transfer and generalization in children with cerebral palsy.

Personal reflection

During the research I conducted on the existing literature, as mentioned earlier, I encountered some limitations and also realized the lack of both research and clinical application of interventions focused on metacognition in the population with cerebral palsy. This confirmed my initial observation that there still isn’t enough clinically applied data. The positive side was that I came across an approach I had already learned how to apply and use, and at the same time, the knowledge I had fit well with the findings I was uncovering.

Personally, wanting to work with a teenager with cerebral palsy who was following an occupational therapy program, and aiming to work on motor skills—specifically jumps with a rope and one-legged support while integrating them into functional activities—we used the CO-OP intervention, and the results justified our efforts. The most important thing was finding motivation by the teenager during the program and seeing an increase in participation.

I had the opportunity to complete my CO-OP training with Petros Meladakis, MSc, OT and Jolien van den Houten, MHPE, OT under the auspices of the Panhellenic Association of Occupational Therapists, and it was a very pleasant surprise for me to see that the CO-OP approach is used in the pediatric population with cerebral palsy. In this way, the knowledge I gained from the seminar found application through the literature, both in the existing knowledge I already had and the new knowledge I acquired through my research.

REFERENCES:

Almond, N. M., & Chakrabarty, S. (2017). A review of cerebral palsy - aetiology, current understanding and treatment: A call for action. Horizons in Neuroscience Research, 29, 1–88.

Andrade, S. (2023). Cognitive strategies and metacognition in occupational therapy for a long COVID-19 patient: a single case report. Brazilian Journal of Occupational Therapy, 31, 1–10. https://doi.org/10.1590/2526-8910.ctoRE265434642

Bares, C. B. (2011). Emerging Metacognitive Processes During Childhood: Implications for Intervention Development with Children. Child and Adolescent Social Work Journal, 28(4), 291–299. https://doi.org/10.1007/s10560-011-0233-1

Bar-Haim, S., Harries, N., Nammourah, I., Oraibi, S., Malhees, W., Loeppky, J., Perkins, N. J., Belokopytov, M., Kaplanski, J., & Lahat, E. (2010). Effectiveness of motor learning coaching in children with cerebral palsy: A randomized controlled trial. Clinical Rehabilitation, 24(11), 1009–1020. https://doi.org/10.1177/0269215510371428

Bottcher, L. (2010). Children with spastic cerebral palsy, their cognitive functioning, and social participation: A review. Child Neuropsychology, 16(3), 209–228. https://doi.org/10.1080/09297040903559630

Bottcher, L., Flachs, E. M., & Uldall, P. (2010). Attentional and executive impairments in children with spastic cerebral palsy. Developmental Medicine and Child Neurology, 52(2). https://doi.org/10.1111/j.1469-8749.2009.03533.x

Burtner, P. A., Leinwand, R., Sullivan, K. J., Goh, H. T., & Kantak, S. S. (2014). Motor learning in children with hemiplegic cerebral palsy: Feedback effects on skill acquisition. Developmental Medicine and Child Neurology, 56(3), 259–266. https://doi.org/10.1111/dmcn.12364

Cameron, D., Craig, T., Edwards, B., Missiuna, C., Schwellnus, H., & Polatajko, H. J. (2017). Cognitive Orientation to daily Occupational Performance (CO-OP): A New Approach for Children with Cerebral Palsy. Physical and Occupational Therapy in Pediatrics, 37(2), 183–198. https://doi.org/10.1080/01942638.2016.1185500

Chatzipanteli, A., & Digelidis, N. (2011). The influence of metacognitive prompting on students’ performance in a motor skills test in physical education. International Journal of Sports Science and Engineering, 5(2), 93–98.

García-Galant, M., Blasco, M., Laporta-Hoyos, O., Berenguer-González, A., Moral-Salicrú, P., Ballester-Plané, J., Caldú, X., Miralbell, J., Alonso, X., Medina-Cantillo, J., Povedano-Bulló, E., Leiva, D., Boyd, R. N., & Pueyo, R. (2023). A randomized controlled trial of a home-based computerized executive function intervention for children with cerebral palsy. European Journal of Pediatrics, 182(10), 4351–4363. https://doi.org/10.1007/s00431-023-05072-3

Ghorbani, N., Rassafiani, M., Izadi-Najafabadi, S., Yazdani, F., Akbarfahimi, N., Havaei, N., & Gharebaghy, S. (2017). Effectiveness of cognitive orientation to (daily) occupational performance (CO-OP) on children with cerebral palsy: A mixed design. Research in Developmental Disabilities, 71(August 2016), 24–34. https://doi.org/10.1016/j.ridd.2017.09.007

Hildenbrand, L., & Sanchez, C. A. (2022). Metacognitive accuracy across cognitive and physical task domains. Psychonomic Bulletin and Review, 29(4), 1524–1530. https://doi.org/10.3758/s13423-022-02066-4

Houldin, A., McEwen, S. E., Howell, M. W., & Polatajko, H. J. (2018). The cognitive orientation to daily occupational performance approach and transfer: A scoping review. OTJR Occupation, Participation and Health, 38(3), 157–172. https://doi.org/10.1177/1539449217736059

Ivanova, V., & Zagora, S. (2004). METACOGNITIVE COMPONENTS IN THE STRUCTURE OF. 5(October 2016), 8–10.

Jackman, M., Novak, I., Lannin, N., Froude, E., Miller, L., & Galea, C. (2018). Effectiveness of Cognitive Orientation to dailyĞOccupational Performance over and above functional hand splints for children with cerebral palsy or brain injury: A randomized controlled trial. BMC Pediatrics, 18(1), 1–12. https://doi.org/10.1186/s12887-018-1213-9

Katz, N., Hartman-maeir, A., & Scopus, M. (2015). Ccupational performance and metacognition. April 1997.

Levac, D., Wishart, L., Missiuna, C., & Wright, V. (2009). The application of motor learning strategies within functionally based interventions for children with neuromotor conditions. Pediatric Physical Therapy, 21(4), 345–355. https://doi.org/10.1097/PEP.0b013e3181beb09d

Levin, M. F., & Demers, M. (2021). Motor learning in neurological rehabilitation. Disability and Rehabilitation, 43(24), 3445–3453. https://doi.org/10.1080/09638288.2020.1752317

MacIntyre, T. E., Igou, E. R., Campbell, M. J., Moran, A. P., & Matthews, J. (2014). Metacognition and action: A new pathway to understanding social and cognitive aspects of expertise in sport. Frontiers in Psychology, 5(October), 1–12. https://doi.org/10.3389/fpsyg.2014.01155

Missiuna, C., Mandich, A. D., Polatajko, H. J., & Malloy-Miller, T. (2001). Cognitive Orientation to Daily Occupational Performance (CO-OP): Part I -Theoretical Foundations. Physical and Occupational Therapy in Pediatrics, 20(42038), 69–81. https://doi.org/10.1080/J006v20n02_05

Nagelkop, N. D., Rosselló, M., Aranguren, I., Lado, V., Ron, M., & Toglia, J. (2021). Using Multicontext Approach to Improve Instrumental Activities of Daily Living Performance after a Stroke: A Case Report. Occupational Therapy in Health Care, 35(3), 249–267. https://doi.org/10.1080/07380577.2021.1919954

Öhrvall, A. M., Hofgren, C., Lindquist, B., Bergqvist, L., Himmelmann, K., Opheim, A., Sjöwall, D., Brock, K., & Peny-Dahlstrand, M. (2024). Intervention with the CO-OP Approach leads to a transfer effect over time to untrained goals for children with cerebral palsy or spina bifida. Disability and Rehabilitation, 46(12), 2512–2521. https://doi.org/10.1080/09638288.2023.2225875

Peny-Dahlstrand, M., Hofgren, C., Lindquist, B., Bergqvist, L., Himmelmann, K., Opheim, A., Sjöwall, D., Brock, K., & Öhrvall, A. M. (2023). The Cognitive Orientation to daily Occupational Performance (CO-OP) Approach is superior to ordinary treatment for achievement of goals and transfer effects in children with cerebral palsy and spina bifida–a randomized controlled trial. Disability and Rehabilitation, 45(5), 822–831. https://doi.org/10.1080/09638288.2022.2043459

Polatajko, H. J., Mandich, A. D., Missiuna, C., Miller, L. T., Macnab, J. J., Malloy-Miller, T., & Kinsella, E. A. (2013). Cognitive orientation to daily occupational performance (CO-OP): Part III-The protocol in brief. Children with Developmental Coordination Disorder: Strategies for Success, 20(2), 107–124. https://doi.org/10.4324/9780203048481-10

Polatajko, H., Mandich, A., Miller, L., & Macnab, J. (2001). Cognitive Orientation to Daily Occupational Performance (CO-OP). Physical & Occupational Therapy In Pediatrics, 20(2), 83–106. https://doi.org/10.1300/j006v20n02_06

Rahnev, D. (2023). Measuring metacognition: A comprehensive assessment of current methods. PsyArXiv, July 2023, 1–62. https://doi.org/10.1038/s41467-025-56117-0

Rice, M. S., & Hernandez, H. G. (2006). Frequency of knowledge of results and motor learning in persons with developmental delay. Occupational Therapy International, 13(1), 35–48. https://doi.org/10.1002/oti.206

Robert, L., Conway-smith, B., & West, R. L. (2023). Proceedings of the Annual Meeting of the Cognitive Science Metacognitive skill : how it is acquired.

Sadnicka, A., Strudwick, A. M., Grogan, J. P., Manohar, S., & Nielsen, G. (2025). Going ‘meta’: a systematic review of metacognition and functional neurological disorder. Brain Communications, 7(1), 1–12. https://doi.org/10.1093/braincomms/fcaf014

Scammell, E. M., Bates, S. V., Houldin, A., & Polatajko, H. J. (2016). The Cognitive Orientation to daily Occupational Performance (CO-OP): A scoping review. Canadian Journal of Occupational Therapy, 83(4), 216–225. https://doi.org/10.1177/0008417416651277

Simon, D. A., Bjork, R. A., & Angeles, L. (2014). Metacognition in Motor Learning. August 2001. https://doi.org/10.1037//0278-7393.27.4.907

Sousa, L. K., Brandão, M. B., Curtin, C. M., & Magalhães, L. C. (2020). A Collaborative and Cognitive-based Intervention for Young People with Cerebral Palsy. Canadian Journal of Occupational Therapy, 87(4), 319–330. https://doi.org/10.1177/0008417420946608

Souto, D. O., Cruz, T. K. F., Fontes, P. L. B., & Haase, V. G. (2020). Motor imagery in children with unilateral cerebral palsy: a case–control study. Developmental Medicine and Child Neurology, 62(12), 1396–1405. https://doi.org/10.1111/dmcn.14672

Stadskleiv, K. (2020). Cognitive functioning in children with cerebral palsy. Developmental Medicine and Child Neurology, 62(3), 283–289. https://doi.org/10.1111/dmcn.14463

Sugiyama, T., Schweighofer, N., & Izawa, J. (2023). Reinforcement learning establishes a minimal metacognitive process to monitor and control motor learning performance. https://doi.org/10.1038/s41467-023-39536-9

Tayyare, B. Ç. (2023). Cerebral palsy and executive functions : Inhibitory control and cognitive flexibility skills. June 2022, 1–14. https://doi.org/10.1002/pits.22957

Thorpe, D. E., & Valvano, J. (2020). The Effects of Knowledge of Performance and Cognitive Strategies on Motor Skill Learning in Children with Cerebral Palsy. October. https://doi.org/10.1097/00001577-200214010-00002

Veenman, M. V. J., Van Hout-Wolters, B. H. A. M., & Afflerbach, P. (2006). Metacognition and learning: Conceptual and methodological considerations. Metacognition and Learning, 1(1), 3–14. https://doi.org/10.1007/s11409-006-6893-0

Whittingham, K., Bodimeade, H. L., Lloyd, O., & Boyd, R. N. (2014). Everyday psychological functioning in children with unilateral cerebral palsy: Does executive functioning play a role? Developmental Medicine and Child Neurology, 56(6), 572–579. https://doi.org/10.1111/dmcn.12374

Zwicker, J. G., & Harris, S. R. (2009). A reflection on motor learning theory in pediatric occupational therapy practice. Canadian Journal of Occupational Therapy, 76(1), 29–37. https://doi.org/10.1177/000841740907600108