Beyond core symptoms: the association between caregiver anxiety and ADHD symptom severity and metacognitive awareness in children.

Abstract

This study examined the association between caregiver anxiety, ADHD symptom severity, and metacognitive awareness in children with attention-deficit/hyperactivity disorder (ADHD), and evaluated whether metacognitive awareness mediates the relationship between caregiver anxiety and ADHD symptom severity. This cross-sectional study included children aged 7-17 years diagnosed with ADHD and their primary caregivers. Caregiver anxiety was assessed using the Beck Anxiety Inventory (BAI). Children's ADHD symptom severity was evaluated with the Atilla Turgay Disruptive Behavior Disorders Rating Scale, metacognitive awareness with the Junior Metacognitive Awareness Inventory (Jr.MAI), and overall clinical severity with the Clinical Global Impression - Severity scale (CGI-S). Group comparisons were conducted based on caregiver anxiety severity, and correlation, multiple regression, and mediation analyses were performed. Children of caregivers with higher anxiety severity exhibited significantly greater total ADHD symptom severity, particularly in hyperactivity and oppositional defiant symptoms. Metacognitive awareness was negatively correlated with ADHD symptom severity. In regression analyses, metacognitive awareness and CGI-S independently predicted ADHD symptom severity, whereas caregiver anxiety severity did not remain a significant predictor. Mediation analyses indicated that metacognitive awareness did not significantly mediate the relationship between caregiver anxiety and ADHD symptom severity. Caregiver anxiety is associated with increased ADHD symptom severity, particularly behavioral dysregulation domains. Although metacognitive awareness does not function as a mediator, its inverse association with symptom severity highlights its potential protective role. These findings underscore the importance of addressing both caregiver mental health and children's metacognitive skills in comprehensive ADHD interventions.