Assessing Executive Function Beyond Motor Challenges: Understanding Planning in Cerebral Palsy through a Metacognitive Lens

Abstract

Planning entails the ability to formulate and execute goal-directed actions. Difficulties with planning are increasingly recognised in people with cerebral palsy (CP), alongside broader executive function vulnerabilities that affect self-regulation. However, characterising these difficulties in CP remains challenging because many standardised clinical measures embed motor, speech, or perceptual demands that can complicate valid interpretation of ability. Planning also relies on metacognitive monitoring, which supports evaluation of progress and strategic adjustment, yet this process is rarely made explicit in assessment.

This thesis examined planning in CP through a validity-focused and metacognitive lens. First, a meta-analysis of executive function assessment in children with CP showed that the validity of cognitive assessment is closely tied to the alignment between task demands and CP-related functional profiles. Second, experimental studies in neurotypical adults examined metacognitive reactivity, whereby eliciting self-evaluations alters ongoing cognition and performance. Across two planning paradigms, explicit monitoring had task-dependent effects. Specifically, prompting metacognitive reflection impaired the acquisition of explicit structural knowledge in Complex Problem Solving, whereas optimality-focused evaluations in the Tower of Hanoi supported reflection and strategic adjustment. Finally, the Tower of Hanoi paradigm was translated to adults with CP, providing novel evidence that monitoring is engaged during planning and that explicit monitoring may support adaptive action selection. Overall, this thesis highlights the need for valid and accessible executive function assessment in CP. It also suggests that explicit monitoring warrants further investigation as a potential compensatory support for planning difficulties, with future work needed to link metacognitive indices to functional outcomes that support independence and autonomy in people with CP.