Social Cognition in Children With ADHD

Abstract

Objective: Despite evidence of social skill deficits in children with ADHD, there is no consensus regarding a social cognitive profile and whether these skills predict behavior. Therefore, a comprehensive battery was used to investigate the relationship between social cognition and behavioral functioning. Method: Children ages 7 to 13 with ADHD (n = 25) and controls (n = 25) completed tests assessing social cognitive domains (affect recognition and theory of mind [ToM]). Parents completed measures of social cognition (pragmatic language ability and empathy), behavioral symptoms, and adaptive functioning. Results: Children with ADHD performed significantly worse on measures of cognitive ToM and affect recognition and received lower ratings of pragmatic language and cognitive empathy than typically developing peers. These domains, particularly pragmatic language, predicted parent ratings of problematic and adaptive behaviors. Conclusion: Results establish a relationship between specific social cognitive abilities and daily functioning, which has implications for treatment.

Keywords

ADD/ADHD ADHD-associated problems social cognition ADHD impairment behavior

Introduction

Many children with ADHD exhibit social skills deficits, such as poor eye contact and difficulty developing relationships with peers (Uekermann et al., 2010). Impairment in social cognitive abilities in ADHD likely contributes to these social skill deficits and general impairment in functioning. Social cognition is a broad domain composed of distinct, but integrated cognitive abilities required for processing social information and successfully navigating social situations. Such abilities include affect recognition, pragmatic language, theory of mind (ToM), and empathy (Martin & McDonald, 2003; Uekermann et al., 2010). Affect recognition includes interpretation of emotions in facial expressions and other nonverbal communication cues (e.g., prosody). Pragmatic language refers to the use of language in a social context and is necessary for communicating and understanding social and emotional intent (Grzadzinski et al., 2011). ToM and empathy are two constructs which the literature suggests are best separated into cognitive and affective components because they have different neuroanatomical correlates, and one process may be intact, while the other is impaired (Shamay-Tsoory & Aharon-Peretz, 2007; Shamay-Tsoory, Aharon-Peretz, & Perry, 2009). Cognitive ToM refers to understanding another person’s thoughts and affective ToM refers to understanding another’s feelings (Beauchamp & Anderson, 2010). Empathy moves beyond recognition to personal identification with another’s thoughts (cognitive empathy) and feelings (affective empathy; Dadds et al., 2008).

There is strong evidence indicating that ADHD symptoms affect learning of non-social information (Parke, Thaler, Etcoff, & Allen, 2020) and may also interfere with adequate learning of social and emotional information (Andrade et al., 2012). These symptoms may prevent early social cognitive development and result in continued delays even after ADHD symptoms are effectively managed. For example, inattention interferes with the ability to focus and sustain attention during conversations or appropriately read social cues during play (Marshall, Evans, Eiraldi, Becker, & Power, 2014). Indeed, performance on sustained attention tasks predicts social problems in both healthy controls and children with ADHD (Andrade, Brodeur, Waschbusch, Stewart, & McGee, 2009). Barkley (2014) has also theorized that poor inhibitory control results in less empathy and poor perspective taking abilities in children with ADHD. Disinhibition of motor, verbal, and behavioral decisions can lead to fewer opportunities for social interaction due to peer rejection. For example, impulsivity involves inappropriately intruding in conversations or play (Abikoff et al., 2002) and is associated with aggression (Sinzig, Morsch, & Lehmkuhl, 2008). Consequently, development of social cognition is potentially thwarted by ADHD symptoms due to fewer opportunities for social learning. Neurobiological evidence also suggests that social cognition is mediated by networks involving the prefrontal cortex (Amodio & Frith, 2006) and dysfunction in this region is consistently implicated in children with ADHD (Friedman & Rapoport, 2015). Studies indicate functional differences between control and ADHD groups when processing social and emotional stimuli (Ibáñez et al., 2011). Taken together, theory and prior research suggest that social cognitive deficits are present in some children with ADHD.

Evidence regarding the profile of social cognitive deficits in children with ADHD is somewhat limited. Affect recognition deficits are most consistently demonstrated (Bae, Shin, & Lee, 2009; Bora & Pantelis, 2016; Ibáñez et al., 2011; Pelc, Kornreich, Foisy, & Dan, 2006; Uekermann et al., 2010; Williams et al., 2008). However, studies have largely excluded clinical measures, limiting generalizability of these experimental findings to clinical evaluations. Given that emotion perception (affect recognition) is a basic skill, more complex social cognitive abilities that require accurate emotion perception (e.g., ToM, pragmatic language) are likely affected. Indeed, some evidence suggests that children with ADHD have poor pragmatic language ability (Green, Johnson, & Bretherton, 2014; Staikova, Gomes, Tartter, McCabe, & Halperin, 2013; Väisänen, Loukusa, Moilanen, & Yliherva, 2014), but studies have not included a control group (Geurts & Embrechts, 2008), assessed other language skills (Staikova et al., 2013; Väisänen et al., 2014), or examined community samples that were not formally diagnosed with ADHD (Leonard, Milich, & Lorch, 2011). There are also mixed results across studies regarding deficits in ToM (Bora & Pantelis, 2016; Charman, Carroll, & Sturge, 2001; Mary et al., 2016) and empathy (Braaten & Rosen, 2000; Demurie, De Corel, & Roeyers, 2011; Gumustas, Yilma, Yulaf, Gokce, & Sabuncuoglu, 2017). Discrepant findings may be due to combining cognitive and affective components of ToM and empathy, even though these are distinct abilities (Dadds et al., 2008). Therefore, the current study separated cognitive and affective components of ToM to provide further insight into these relative strengths and weaknesses, which could have implications for intervention. For example, children with ADHD may be at increased risk for affective difficulties due to emotion dysregulation (Barkley, 2014). Conversely, cognitive components may be more affected due to deficits in executive functioning, which may impact cognitive ToM and empathy (Green, Johnson, & Bretherton, 2014; Uekermann et al., 2010).

Few studies have investigated the relationship between social cognitive deficits and daily behavior in children with ADHD. Available evidence demonstrates an association between parent ratings of pragmatic language, aggression, emotional difficulties, and problems with peers (Hawkins, Gathercole, Astle, & Holmes, 2016; Helland, Lundervold, Heimann, & Posserud, 2014). Performance on measures of affect recognition have also been associated with self-ratings of interpersonal problems (Pelc et al., 2006) and teacher ratings of aggression (Bae et al., 2009). However, other studies suggest that children show intact social cognition on objective measures but have difficulty utilizing these skills in daily life (de Boo & Prins, 2007). For example, Charman and colleagues (2001) found that children with ADHD were rated as less socially competent by parents, but they performed similar to typically developing peers on an advanced ToM task. Research examining typically developing peers relative to other clinical populations, such as autism spectrum disorder (Magiati, Tay, & Howlin, 2014) and schizophrenia (Thaler, Allen, Sutton, Vertinski, & Ringdahl, 2013; Thaler, Sutton, & Allen, 2014), indicate that social cognition and communication predict adaptive functioning, although this relationship in children with ADHD has yet to be examined. With this considered, social cognitive deficits in ADHD could affect social connections and effective communication, which is integral to daily functioning.

To enhance understanding of these issues, this study examined social cognition in children with ADHD by including clinical measures, separating cognitive and affective components of ToM and empathy, and assessing functional outcomes relative to control participants. As facial affect recognition difficulties are the most consistently demonstrated finding in the literature (Bora & Pantelis, 2016), it was anticipated that children with ADHD would have more difficulty with affective components of social cognition (affect recognition, affective ToM, and affective empathy). Social cognitive abilities were expected to predict both adaptive and problematic behaviors, such that better social cognitive abilities would predict more adaptive behaviors and social cognitive deficits would predict problematic behaviors.

Method

Participants

Participants included children ages 7 to 13 years consisting of 25 healthy controls and 25 participants diagnosed with ADHD. Children were included in the ADHD group if they received a diagnosis of ADHD-Combined presentation (ADHD-C) or ADHD-Inattentive presentation (ADHD-I) from a psychologist or physician. The Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present and Lifetime Version (K-SADS-PL) was used to confirm diagnoses of ADHD. Participants were excluded if English was not their primary language or they had comorbid autism spectrum disorder, traumatic brain injury, or other neurological condition. Participants were excluded from the control group if they had a Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) diagnosis as determined by the K-SADS-PL or if they had first-degree relative with ADHD based on a standardized family history interview. All participants in the ADHD group abstained from taking ADHD medication 24 hours prior to testing.

Measures

Intelligence

The Wechsler Intelligence Scale for Children, Fifth Edition (WISC-V; Wechsler, 2014) was administered to all children to characterize overall intelligence and verbal abilities. The WISC-V is an intelligence battery for children between 6 and 16 years of age, which includes 10 core subtests that compose five indexes (Verbal Comprehension, Visual Spatial, Fluid Reasoning, Working Memory, and Processing Speed).

Social cognitive abilities

Affect recognition

The Developmental Neuropsychological Assessment, Second Edition (NEPSY-II; Korkman, Kirk, & Kemp, 2007) Affect Recognition subtest was administered, which involves asking whether two faces show the same affect followed by a second task asking for the selection of two photos from three to four with the same affect. A third task requires participants to select one of four faces that show the same affect as the photo at the top of the page. Finally, participants were briefly shown a face and then asked to select two photos that depict the same affect as the photo previously seen. This measure was chosen because it is the only available clinical measure in children, and the NEPSY-II validity study found significantly lower performance in children with ADHD relative to controls (Korkman et al., 2007).

Pragmatic language

The Children’s Communication Checklist–2 (CCC-2; Bishop, 2003) is a 70-item caregiver rating scale used to assess each participant’s language skills. Parents were asked to rate the frequency that the child demonstrates each communication skill. For the purposes of this study, the sum of the initiation, context, nonverbal communication, social relations, and interests scales were for Pragmatic Language. This measure is widely used in the literature due to its high sensitivity, internal consistency, and interrater reliability (Adams, Green, Gilchrist, & Cox, 2002; Bignell & Cain, 2007). Parent ratings of pragmatic language were used as a cognitive measure because these scales correlate highly with objective measures of pragmatic language (Bishop, 2003). High raw scores on the pragmatic language scale indicate poorer abilities (Adams, Green, Gilchrist, & Cox, 2002).

Affective ToM

In the Children’s Version of the Reading the Mind in the Eyes Test (Eyes Test; Baron-Cohen, Wheelwright, Spong, Scahill, & Lawson, 2001), participants were presented with items comprised of photographs of the eye-region with four words describing emotions. Participants were prompted to state which emotion word was best captured by the eyes. The Eyes Test has been shown to differentiate clinical from control groups and has adequate test–retest reliability and convergent validity with other measures of social cognition (Olderbak et al., 2015). The NEPSY-II Contextual task was also included as a measure of affective ToM. This measure asks participants to select the appropriate facial affect based on a picture of a social situation. While these measures may overlap with other aspects of social cognition, they were selected because the Eyes Test is widely used and the NEPSY-II Contextual task is the only similar clinical measure.

Cognitive ToM

Happé’s Strange Stories were developed to measure higher order ToM abilities (Happé, 1994). The types of stories are pretend, joke, lie, white lie, figure of speech, misunderstanding, double bluff, sarcasm, persuasion, contrary emotions, appearance/reality, and forgetting. The examiner read the story aloud and then presented the physical stimulus to minimize memory components. After each story was read, the participant was asked a comprehension question (“Was it true what X said?”) and a justification question (“Why did X say that?”). Answers to justification questions were scored as correct or incorrect based on mental and physical state criteria described by Happé (1994). This measure was selected because it had been used in previous studies examining children with ADHD and demonstrates high interrater reliability (Charman et al., 2001).

Cognitive and affective empathy

The Interpersonal Reactivity Index (IRI; Davis, 1983) is a 28-item self-report scale designed to measure both cognitive and emotional components of empathy. The Perspective Taking and Fantasy scales were developed to measure cognitive empathy and the Empathic Concern and Personal Distress scales were developed to measure affective empathy (Davis, 1983). This measure was adapted for completion by parents regarding their child’s empathy and has been validated for use in children with ADHD (Demurie et al., 2011). The Fantasy scale examines the tendency to identify with fictional characters’ emotions and actions. Perspective Taking measures the child’s tendency to take on the psychological point of view of others. Empathic Concern examines a child’s concern for others and sympathy for others in physical or emotional distress. Personal Distress is designed to capture the emotional distress that a child feels when others are in stressful situations.

Behavioral functioning

The Behavior Assessment System for Children–Second Edition (BASC-2; Reynolds & Kamphaus, 2004) is a measure of social, emotional, and behavioral functioning in children ages 2 to 18 years of age. The Parent Rating Scales (PRS) for Externalizing Problems, Behavioral Symptoms, and Adaptive Skills were used in the present study. The Externalizing Problems Scale is composed of Hyperactivity, Aggression, and Conduct Problems ratings. The Behavioral Symptoms Scale also includes ratings of Atypicality, Withdrawal, and Attention Problems. The Adaptive Skills Scale is comprised of Adaptability, Social Skills, Leadership, Activities of Daily Living, and Functional Communication ratings.

Procedure

Participants were recruited from the community at large and from community mental health centers. They received monetary compensation (US $40) and parents of participants with ADHD also received a brief report with their child’s results and recommendations. After confirming participant eligibility, the social cognitive and other tests were administered in a fixed order. Trained doctoral-level graduate students conducted all testing, which was completed in a quiet private room. Participants took breaks whenever requested or as deemed appropriate by the examiner to control for fatigue effects, alleviate anxiety, and maintain motivation.

Results

Demographic data are provided in Table 1. Groups did not significantly differ on age, gender, ethnicity, or mean gross household income. Within the ADHD group, 68% percent were currently prescribed a psychostimulant medication.

Table 1.

Demographics by Group.

Variable	Group		F	p	Cohen’s d
	Control (n = 25)	ADHD (n = 25)
	M (SD)	M (SD)
Age	10.07 (1.90)	10.57 (2.09)	0.78	.38	−.25
Gross family income	122,560.00 (77,051.90)	99,033.3 (72,650.50)	1.21	.28	.31
WISC-V FSIQ	107.44 (10.65)	98.08 (15.15)	6.39	.015	.71
WISC-V VCI	110.40 (12.06)	101.20 (13.85)	6.27	.016	.71
WISC-V VSI	107.52 (13.15)	100.12 (11.55)	4.47	.04	.60
WISC-V FRI	104.88 (10.80)	103.76 (16.48)	0.08	.78	.08
WISV-V WMI	102.12 (12.77)	93.52 (15.43)	4.61	.04	.61
WISV-V PSI	101.16 (13.29)	88.76 (12.14)	11.86	.001	.97
			χ²	p
Gender (% male)	60.0	76.0	1.47	.23	.35
Ethnicity (%)			6.68	.25	.79
Caucasian	72.0	44.0
African American	8.0	12.0
Hispanic/Latino	4.0	16.0
Asian American	4.0	4.0
Multi-racial	12.0	24.0
Diagnoses		Frequency (n)
ADHD-Combined		16
ADHD-Inattentive		9
ODD		11

Note. WISC-V = Wechsler Intelligence Scale for Children, Fifth Edition; FSIQ = Full Scale IQ; VCI = Verbal Comprehension Index; VSI = Visual Spatial Index; FRI = Fluid Reasoning Index; WMI = Working Memory Index; PSI = Working Memory Index; ODD = oppositional defiant disorder.

A mixed model ANOVA was used to examine differences between the control and ADHD groups on the social cognition measures. The mixed-model ANOVA included group (control or ADHD) as a between-subjects factor and performance on social cognition measures (affect recognition, pragmatic language, affective ToM, cognitive ToM, affective empathy, and cognitive empathy) as a within-subjects factor. Results of the ANOVA indicated a significant main effect for social cognition, F(3.11, 149.16) = 92.8, p < .0001, η² = .659, as well as a significant social cognition by group interaction effect, F(3.11, 149.16) = 29.0, p < .0001, η² = .377. The main effect for group was not significant, F(1, 48) = 2.1, p = .10, η² = .057. Given significant group differences on IQ, the analyses were repeated with IQ included as a covariate. This analysis produced a significant main effect for group, F(1, 47) = 4.4, p < .05, η² = .085, and a significant social cognition by group interaction effect, F(3.00, 141.06) = 23.2, p < .0001, η² = .330. The main effect for social cognition was not significant, F(3.00, 141.06) = 1.32, p = .26, η² = .027, nor was the IQ by social cognition interaction effect, F(3.00, 141.06) = 1.82, p = .15, η² = .037, or the effect for IQ, F(1, 47) = 1.96, p = .17, η² = .040. The social cognition by group interaction effect is presented in Figure 1. Because the effect was present regardless of whether IQ was included as a covariate and comparison of corrected and uncorrected scores indicated a similar pattern or results, the figure presents the scores without correction for IQ. In the figure, raw scores were converted to standardized (z) scores using the means and standard deviations from the control group to facilitate comparisons of relative strengths and weaknesses between groups across the social cognitive domains. Lower scores indicate worse performance for all social cognitive domains.

Figure 1.

Social cognition performance by group.

To further evaluate the interaction effect, ANOVAs were used to evaluate group differences on each of the six social cognitive domains. Results of these analyses are presented in Table 2. Significant differences occurred between the control and ADHD groups for the affect recognition, pragmatic language, cognitive ToM, and cognitive empathy domains. In all cases, the ADHD group exhibited deficits compared with the controls.

Table 2.

Descriptive Statistics and ANOVA Results for Group Comparisons on Social Cognition Measures.

Variable	Control	ADHD	ANOVA
Variable	M (SD)	M (SD)	F	$η_{p}^{2}$
Affect Recognition (SS)	11.6 (2.0)	9.4 (2.5)
Affect Recognition (RS)	27.6 (2.8)	25.5 (3.2)	5.88*	.109
Pragmatic Language (RS)	9.8 (6.7)	29.6 (9.6)	68.19***	.587
Affective ToM (RS)	18.8 (2.7)	18.2 (3.9)	0.53	.007
Cognitive ToM (RS)	43.5 (3.0)	38.0 (6.3)	13.53***	.220
Affective Empathy (RS)	32.9 (6.2)	35.7 (6.7)	2.54	.047
Cognitive Empathy (RS)	29.6 (9.6)	23.6 (9.7)	4.76*	.090

Note. SS = Standard Score; RS = Raw Score; ToM = Theory of Mind.

p < .05. ***p < .001.

Hierarchical multiple regression analyses were then conducted to examine whether social cognitive performance related to functioning. In these analyses, IQ was entered in the first step of the regression, followed by the social cognitive variables that were shown to significantly differ between the groups. Regressions predicted BASC-2 externalizing raw scores, behavioral symptoms raw scores, and adaptive skills raw scores from cognitive empathy, affect recognition, cognitive ToM, and pragmatic language. Mean, standard deviations, and bivariate correlations for all pairs of variables in the analysis are included in Table 3.

Table 3.

Means and Correlations Among Social Cognition Variables and BASC-2 Scores.

	Externalizing problems	Behavioral symptoms	Adaptive skills
	M (SD)	M (SD)	M (SD)
Group
Control	44.5 (8.0)	43.6 (6.3)	55.6 (7.1)
ADHD	61.5 (10.4)	66.2 (9.9)	39.7 (6.6)
Social cognition variable
Affect Recognition	−.25	−.32*	.34*
Pragmatic Language	.59***	.74***	−.74***
Affective ToM	−.14	−.22	.27
Cognitive ToM	−.48***	−.51***	.61***
Affective Empathy	.02	.10	−.04
Cognitive Empathy	−.51***	−.35*	.40**

Note. BASC-2 = Behavior Assessment System for Children–Second Edition; ToM = Theory of Mind.

p < .05. **p < .01. ***p < .001.

After controlling for IQ, increases in cognitive empathy scores were associated with lower externalizing raw scores (b = −1.168, β = −.345, Δr² = .102, p = .004) and increases in pragmatic language scores were associated with increases in externalizing raw scores (b = 1.093, β = .416, Δr² = .128, p = .001). Increases in cognitive ToM scores were associated with increases in adaptive skills (b = 2.299, β = .288, Δr² = .055, p = .01) and increases in pragmatic language scores were associated with decreases in adaptive skills (b = −1.899, β = −.547, Δr² = .221, p < .001). These results suggest that poorer pragmatic language is associated with more externalizing behavior and behavioral symptoms, which are also associated with declines in adaptive skills, even after controlling for other social cognition variables. These findings are summarized in Table 4.

Table 4.

Regression Analyses for Social Cognitive Performance’s Incremental Prediction of Problem and Prosocial Behaviors.

Dependent variable	Predictors	Β	T	F	R ²	ΔR²	ΔF
Externalizing problems
Model 1	FSIQ	−.244	1.743	3.04	.06	—	—
Model 2	FSIQ	−.15	1.15	8.999	.28	.22	14.13
Model 2	CEmp	−.48	3.76
Model 3	FSIQ	−.10	−0.82	7.16	.32	.04	2.80
	CEmp	−.48	3.82
	AffRec	−.21	1.67
Model 4	FSIQ	.07	0.46	6.76	.38	.06	4.10
	CEmp	−.40	3.19
	AffRec	−.11	−0.89
	CToM	−.34	2.02
Model 5	FSIQ	.09	0.67	8.99	.51	.13	11.57
	CEmp	−.34	3.01
	AffRec	−.03	−0.25
	CToM	−.21	1.34
	PragLang	.42	3.40
Behavioral symptoms
Model 1	FSIQ	−.26	1.88	3.53	.07	—	—
Model 2	FSIQ	−.20	1.45	4.49	.16	.61	5.14
Model 2	CEmp	−.31	2.27
Model 3	FSIQ	−.14	1.06	4.61	.23	.07	4.23
	CEmp	−.31	2.33
	AffRec	−.27	2.06
Model 4	FSIQ	.08	0.49	5.38	.32	.09	6.14
	CEmp	−.21	1.63
	AffRec	−.15	1.14
	CToM	−.43	2.48
Model 5	FSIQ	.11	0.90	13.62	.61	.28	31.84
	CEmp	−.13	1.27
	AffRec	−.03	−0.26
	CToM	−.24	1.72
	PragLang	.62	5.64
Adaptive skills
Model 1	FSIQ	.33	2.42	5.83	.11	−	−
Model 2	FSIQ	.26	1.96	6.67	.22	.11	6.80
Model 2	CEmp	.34	2.61
Model 3	FSIQ	.20	1.56	6.59	.30	.08	5.24
	CEmp	.34	2.71
	AffRec	.29	2.29
Model 4	FSIQ	−.06	−0.44	8.63	.43	.13	10.61
	CEmp	.23	1.91
	AffRec	.15	1.18
	CToM	.52	3.26
Model 5	FSIQ	−.09	−0.81	16.95	.66	.22	28.85
	CEmp	.15	1.61
	AffRec	.03	0.34
	CToM	.35	2.69
	PragLang	−.55	5.37

Note. N = 50. FSIQ = Full Scale IQ; CEmp = Cognitive Empathy; AffRec = Affect Recognition; CToM = Cognitive Theory of Mind; PragLang = Pragmatic Language.

p < .05. **p < .01. ***p < .001.

Discussion

Children with ADHD exhibit social problems, which may result from underlying social cognition deficits (Uekermann et al., 2010). The literature is limited due to the inclusion of few measures of social cognitive abilities and combining cognitive and affective domains in previous studies. Thus, the current study used a comprehensive battery of social cognitive tests to compare relative differences in social cognitive abilities in children with ADHD, separately considering affective and cognitive domains. In the current study, children with ADHD received worse scores than the control group across measures of affect recognition, pragmatic language, cognitive ToM, and cognitive empathy. Significant differences between groups on the social cognitive measures were characterized by moderate to large effects sizes. Contrary to expectations, children with ADHD had more difficulty with cognitive components of social cognition in comparison with affective components (affective ToM and empathy). In retrospect, this is understandable given the strong association between executive functioning and cognitive aspects of social cognition (Uekermann et al., 2010). As in prior studies with experimental measures, children with ADHD performed significantly lower than typically developing peers on a facial affect recognition task (Ibáñez et al., 2011; Pelc et al., 2006; Sinzig et al., 2008). Although there were group differences, both the control and ADHD group scored within the average range and did not demonstrate impairment on this clinical measure. As few studies have used affect recognition measures whose scores can be compared with national norms, it is unclear whether differences reported in other studies reflect some level of impairment or the relative difference, but average performance noted in the present study. One explanation of findings is that children within both groups were of higher socioeconomic status and the control group’s general cognitive abilities were slightly above the normative sample. Social cognitive deficits in children with ADHD may be better demonstrated in a more diverse sample. However, obtaining research participants of lower socioeconomic status is a common difficulty in research studies due to barriers, such as limited time and transportation (Ford et al., 2008). Despite these limitations, the current study indicates a pattern of relatively higher social cognitive skills in typically developing peers compared with children with ADHD. Therefore, results are discussed considering the relative pattern of strengths and weaknesses demonstrated in the present study.

Study results provide further evidence that children with ADHD have intact structural language and verbal intelligence but may have difficulties with pragmatic language (Geurts & Embrechts, 2008; Green et al., 2014; Hawkins et al., 2016; Staikova et al., 2013; Väisänen et al., 2014). This is expected given that pragmatic language is mediated by neural networks involving the prefrontal lobe (Ryan et al., 2015). Findings are also consistent with prior research indicating weaknesses in advanced cognitive ToM (Buitelaar, van der Wess, Swaab-Barneveld, & van der Gaag, 1999; Hutchins et al., 2016; Sodian & Hülsken, 2005) and cognitive empathy (Demurie et al., 2011; Schwenck et al., 2011). Perhaps if children have difficulty understanding another’s point of view (cognitive ToM), they are less likely to envision themselves from another’s perspective (cognitive empathy). Overall, the current study and literature indicate that ToM and empathy should be considered in evaluations with this population. Furthermore, deficits in these skills should not solely be used in differentiating between diagnoses of ADHD and autism spectrum disorder (Demurie et al., 2011). Current study findings indicate that children with ADHD may be emotionally reactive to others but they are less likely to understand and take another’s perspective. Thus, cognitive ToM and empathy may be useful targets for intervention to improve social skills. For example, the use of social stories and instruction on understanding emotional scripts may be beneficial (Ornaghi, Brockmeier, & Grazzani, 2014).

Based on the current findings, affective empathy and ToM do not appear to be impaired in children with ADHD. Prior studies which demonstrated significant differences between groups may be complicated by the cognitive components of study tasks, such as interpreting stories or pictures. Parents rated children with ADHD slightly higher on affective empathy, but results were not statistically significant. An interpretation of these findings is that children with ADHD appear more empathetic at times due to emotion dysregulation because of deficits in executive functioning (Barkley, 2014). For example, questions assessing affective empathy (e.g., Being in a tense emotional situation scares my child) may be more reflective of emotion dysregulation rather than genuine empathy. Emotional reactions from others produce salient stimuli which may affect children with ADHD more than their peers. For example, if another child is crying, a child with ADHD may attend to this noise at the expense of attending to other relevant information (e.g., classroom instruction or other social cues). They may also have difficulty regulating their reaction to another’s distress and take longer than their peers to calm down from distress or excitement. Thus, children with ADHD may experience affective empathy, but inappropriately regulate their reactions. Difficulty with cognitive ToM could also impact their ability to accurately understand the complexity of reasons behind another’s emotions. Rather than addressing whether a child responds emotionally to others, it may be more important to assess and treat the adaptiveness of their emotional responses in stressful situations.

Regression analyses in the current study demonstrated that greater parent-reported impairment in social cognition (pragmatic language and cognitive empathy) and performance on a cognitive ToM task explained a substantial amount of variance when used to predict problematic and adaptive behaviors. Findings may be partially attributable to parents having a global view of their child as unskilled or skilled. However, their performance on an objective measure of social cognition also contributes to this finding. Results are consistent with the literature indicating children with ADHD are at risk for behavioral and adaptive difficulties (Ashwood et al., 2015). In addition, study findings establish a relationship between specific social cognitive abilities and daily functioning. Cognitive empathy was associated with externalizing symptoms and cognitive ToM was associated with adaptive skills. Findings suggest that identifying with another’s emotions may play a role in decreasing externalizing behavior. Understanding another’s emotional intent may relate to better expression of prosocial skills. Pragmatic language was the best predictor of behavioral and adaptive functioning difficulties. The results are consistent with research demonstrating the importance of language abilities for these outcome variables (Helland et al., 2014; Leonard et al., 2011; Ryan et al., 2015). When children have limited pragmatic language, they are unable to express frustration verbally, leading to externalizing symptoms (Helland et al., 2014). They may also internalize this frustration, resulting in increased behavioral symptoms (e.g., mood and anxiety). Pragmatic language is also essential to adaptive skills, including demonstrating prosocial behavior (e.g., leadership) and independently performing activities of daily living. Given the importance of pragmatic language to functional outcomes, inclusion of this domain or referral to speech and language pathology is recommended when assessing children with ADHD.

The current study is limited with respect to a small sample size including children with different ADHD presentations and comorbid diagnoses. Research suggests children with a combined presentation are more at risk for aggression (Semrud-Clikeman, 2010), whereas children with the inattentive presentation are more at risk for deficits in social knowledge and withdrawal (Marshall et al., 2014). Both ADHD presentations and children with comorbid oppositional defiant disorder (ODD) are at risk for limited opportunities for social learning due to social withdrawal or peer rejection due to disruptive behavior. These behavioral symptom profiles could potentially impact social cognition by differentially affecting social cognition domains. For example, prominent symptoms of inattention could lead to less awareness of subtle changes in facial expression. Future studies may separately examine these groups with a larger sample to determine differences in social cognition profiles. There are also limitations regarding assessment measures, with most providing no standardized norms or clearly differentiated constructs. For example, the Eyes Test may describe cognitive states (e.g., puzzled) rather than emotions. Future directions include consensus in measuring distinct social cognitive constructs and development of clinical measures with normative samples to better understand relative versus normative differences.

In the context of the above limitations, the current study extends the literature by including a control group, examining children formally diagnosed with ADHD, evaluating multiple social cognitive domains allowing for comparisons of relative strengths and weaknesses, and investigating the extent to which social cognitive abilities predict externalizing and adaptive behaviors. Clinical applications include addressing social cognitive deficits in evaluations and recommendations for social skills training targeting relative weaknesses. Future studies are needed to develop additional clinical measures of social cognition for children with normative samples, examine socioeconomically diverse participants, and compare children with different presentations of ADHD and comorbid diagnoses.

Footnotes

Authors’ Note

The contents of this study are original and not under consideration for publication elsewhere. This study was completed in fulfillment of the dissertation requirement at the University of Nevada, Las Vegas, for Elyse M. Parke.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the University Nevada, Las Vegas for the research included in this article.

Author Biographies

Elyse M. Parke earned her PhD in clinical psychology, specializing in neuropsychology, from the University of Nevada, Las Vegas. She is currently a pediatric neuropsychology fellow at Baylor College of Medicine/Texas Children’s Hospital. Her research interests include cognitive deficits and symptomatology in children with ADHD.

Megan L. Becker, MA, is currently a doctoral student in clinical psychology, specializing in neuropsychology, at the University of Nevada, Las Vegas. Her research interests include social cognition, schizophrenia spectrum disorders, cross-cultural neuropsychology, traumatic brain injury, and neurological disorders.

Stacey J. Graves, MA, is a doctoral student in clinical psychology at the University of Nevada, Las Vegas. Her primary research investigates the psychometric properties of ADHD symptom rating scales in children and adults.

Abigail R. Baily, MA, is a doctoral student in clinical psychology, specializing in neuropsychology, at the University of Nevada, Las Vegas.

Michelle G. Paul earned her PhD in clinical psychology in 1997 from the University of Vermont. She is an associate professor in residence, association director of clinical training and director of a community mental health training clinic at the University of Nevada, Las Vegas. She has served the profession as president of the state psychological association and president of the state licensing board. Her areas of expertise and interest include clinical supervision, education, training, and regulation.

Andrew J. Freeman earned his PhD in psychology in 2013 from the University of North Carolina at Chapel Hill. He teaches assessment, statistics, and psychopathology at the University of Nevada, Las Vegas. His primary research areas are evidence-based assessment of youth and chronic irritability.

Daniel N. Allen earned his PhD in clinical psychology in 1993 from the University of South Dakota. He is a professor and director of clinical training at the University of Nevada, Las Vegas, where he teaches psychopathology and neuropsychology. His primary research is in the area of neuropsychology of serious mental illness.

References

Abikoff

H. B.

Jensen

P. S.

Arnold

L. L.

Hoza

Hechtman

Pollack

. . . Wigal

(2002). Observed classroom behavior of children with ADHD: Relationship to gender and comorbidity. Journal of Abnormal Child Psychology, 30, 349-359. doi:10.1023/A:1015713807297

Adams

Green

Gilchrist

Cox

(2002). Conversational behaviour of children with Asperger syndrome and conduct disorder. Journal of Child Psychology and Psychiatry, 43, 679-690. doi:10.1111/1469-7610.00056

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Amodio

D. M.

Frith

C. D.

(2006). Meeting of minds: The medial frontal cortex and social cognition. Nature Reviews Neuroscience, 7, 268-277. doi:10.1038/nrn1884

Andrade

B. F.

Brodeur

D. A.

Waschbusch

D. A.

Stewart

S. H.

McGee

(2009). Selective and sustained attention as predictors of social problems in children with typical and disordered attention ability. Journal of Attention Disorders, 12, 341-352. doi:10.1177/1087054708320440

Andrade

B. F.

Waschbusch

D. A.

Doucet

King

MacKinnon

McGrath

P. J.

. . . Corkum

(2012). Social information processing of positive and negative hypothetical events in children with ADHD and conduct problems and controls. Journal of Attention Disorders, 16, 491-504. doi:10.1177/1087054711401346

Ashwood

K. L.

Tye

Azadi

Cartwright

Asherson

Bolton

(2015). Brief report: Adaptive functioning in children with ASD, ADHD and ASD+ ADHD. Journal of Autism and Developmental Disorders, 45, 2235-2242. doi:10.1007/s10803-014-2352-y

Bae

S. M.

Shin

D. W.

Lee

S. J.

(2009). The effect of impulsivity and the ability to recognize facial emotion on the aggressiveness of children with attention-deficit hyperactivity disorder. Journal of the Korean Academy of Child and Adolescent Psychiatry, 20, 17-22. Retrieved from http://www.koreamed.org/SearchBasic.php?RID=0135JKACAP/2009.20.1.17&DT=1

Barkley

R. A.

(Ed.). (2014). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment. New York, NY: Guilford.

10.

Baron-Cohen

Wheelwright

Spong

Scahill

Lawson

(2001). Are intuitive physics and intuitive psychology independent? A test with children with Asperger Syndrome. Journal of Developmental and Learning Disorders, 5, 47-78. Retrieved from https://www.researchgate.net

11.

Beauchamp

M. H.

Anderson

(2010). SOCIAL: An integrative framework for the development of social skills. Psychological Bulletin, 136, 39-64. doi:10.1037/a0017768

12.

Bignell

Cain

(2007). Pragmatic aspects of communication and language comprehension in groups of children differentiated by teacher ratings of hyperactivity and inattention. British Journal of Developmental Psychology, 25, 499-512. doi:10.1348/026151006X171343

13.

Bishop

D. V. M.

(2003). Children’s Communication Checklist—Revised (2nd ed.). San Antonio, TX: The Psychological Corporation.

14.

Bora

Pantelis

(2016). Meta-analysis of social cognition in attention-deficit/hyperactivity disorder (ADHD): Comparison with healthy controls and autistic spectrum disorder. Psychological Medicine, 46, 699-716. doi:10.1017/S0033291715002573

15.

Braaten

E. B.

Rosen

L. A.

(2000). Self-regulation of affect in attention deficit-hyperactivity disorder (ADHD) and non-ADHD boys: Differences in empathic responding. Journal of Consulting and Clinical Psychology, 68, 313-321. doi:10.1037/0022-006X.68.2.313

16.

Buitelaar

J. K.

van der Wess

Swaab-Barneveld

van der Gaag

R. J.

(1999). Theory of mind and emotion recognition functioning in autistic spectrum disorders and in psychiatric control and normal children. Developmental Psychopathology, 11, 39-58. doi:10.1017/S0954579499001947

17.

Charman

Carroll

Sturge

(2001). Theory of mind, executive function and social competence in boys with ADHD. Emotional and Behavioural Difficulties, 6, 31-49. doi:10.1080/13632750100507654

18.

Dadds

M. R.

Hunter

Hawes

D. J.

Frost

A. D.

Vassallo

Bunn

. . . El Masry

(2008). A measure of cognitive and affective empathy in children using parent ratings. Child Psychiatry & Human Development, 39, 111-122. doi:10.1007/s10578-007-0075-4

19.

Davis

(1983). Measuring individual differences in empathy: Evidence for a multidimensional approach. Journal of Personality and Social Psychology, 44, 113-126. doi:10.1037/0022-3514.44.1.113

20.

de Boo

G. M.

Prins

P. J

. (2007). Social incompetence in children with ADHD: Possible moderators and mediators in social-skills training. Clinical Psychology Review, 27, 78-97. doi:10.1016/j.cpr.2006.03.006

21.

Demurie

De Corel

Roeyers

(2011). Empathic accuracy in adolescents with autism spectrum disorders and adolescents with attention-deficit/hyperactivity disorder. Research in Autism Spectrum Disorders, 5, 126-134. doi:10.1016/j.rasd.2010.03.002

22.

Ford

J. G.

Howerton

M. W.

Lai

G. Y.

Gary

T. L.

Bolen

Gibbons

M. C.

. . . Powe

N. R.

(2008). Barriers to recruiting underrepresented populations to cancer clinical trials: A systematic review. Cancer: Interdisciplinary International Journal of the American Cancer Society, 112, 228-242. doi:10.1002/cncr.23157

23.

Friedman

L. A.

Rapoport

J. L.

(2015). Brain development in ADHD. Current Opinion in Neurobiology, 30, 106-111. doi:10.1016/j.conb.2014.11.007

24.

Geurts

H. M.

Embrechts

(2008). Language profiles in ASD, SLI, and ADHD. Journal of Autism and Developmental Disorders, 38, 1931-1943. doi:10.1007/s10803-008-0587-1

25.

Green

B. C.

Johnson

K. A.

Bretherton

(2014). Pragmatic language difficulties in children with hyperactivity and attention problems: An integrated review. International Journal of Language & Communication Disorders, 49, 15-29. doi:10.1111/1460-6984.12056

26.

Grzadzinski

Di Martino

Brady

Mairena

M. A.

O’Neale

Petkova

. . . Castellanos

F. X.

(2011). Examining autistic traits in children with ADHD: Does the autism spectrum extend to ADHD? Journal of Autism and Developmental Disorders, 41, 1178-1191. doi:10.1007/s10803-010-1135-3

27.

Gumustas

Yilma

Yulaf

Gokce

Sabuncuoglu

(2017). Empathy and facial expression recognition in children with and without attention-deficit/hyperactivity disorder: Effects of stimulant medication on empathic skills in children with attention-deficit/hyperactivity disorder. Journal of Child and Adolescent Psychopharmacology, 27, 433-439. doi:10.1089/cap.2016.0052

28.

Happé

F. G.

(1994). An advanced test of theory of mind: Understanding of story characters’ thoughts and feelings by able autistic, mentally handicapped, and normal children and adults. Journal of Autism and Developmental Disorders, 24, 129-154. doi:10.1007/BF02172093

29.

Hawkins

Gathercole

Astle

Holmes

(2016). Language problems and ADHD symptoms: How specific are the links? Brain Sciences, 6, 50-67. doi:10.3390/brainsci6040050

30.

Helland

W. A.

Lundervold

A. J.

Heimann

Posserud

M. B.

(2014). Stable associations between behavioral problems and language impairments across childhood—The importance of pragmatic language problems. Research in Developmental Disabilities, 35, 943-951. doi:10.1016/j.ridd.2014.02.016

31.

Hutchins

T. L.

Prelock

P. A.

Morris

Benner

LaVigne

Hoza

(2016). Explicit vs. applied theory of mind competence: A comparison of typically developing males, males with ASD, and males with ADHD. Research in Autism Spectrum Disorders, 21, 94-108. doi:10.1016/j.rasd.2015.10.004

32.

Ibáñez

Petroni

Urquina

Torrente

Torralva

Hurtado

. . . Manes

(2011). Cortical deficits of emotional face processing in adults with ADHD: Its relation to social cognition and executive function. Social Neuroscience, 6, 464-481. doi:10.1080/17470919.2011.620769

33.

Korkman

Kirk

Kemp

(2007). NEPSY-II: A developmental neuropsychological assessment. San Antonio, TX: The Psychological Corporation.

34.

Leonard

M. A.

Milich

Lorch

E. P.

(2011). The role of pragmatic language use in mediating the relation between hyperactivity and inattention and social skills problems. Journal of Speech, Language, and Hearing Research, 54, 567-579. doi:10.1044/1092-4388(2010/10-0058)

35.

Magiati

Tay

X. W.

Howlin

(2014). Cognitive, language, social and behavioural outcomes in adults with autism spectrum disorders: A systematic review of longitudinal follow-up studies in adulthood. Clinical Psychology Review, 34, 73-86. doi:10.1016/j.cpr.2013.11.002

36.

Marshall

S. A.

Evans

S. W.

Eiraldi

R. B.

Becker

S. P.

Power

T. J.

(2014). Social and academic impairment in youth with ADHD, predominately inattentive type and sluggish cognitive tempo. Journal of Abnormal Child Psychology, 42, 77-90. doi:10.1007/s10802-013-9758-4

37.

Martin

McDonald

(2003). Weak coherence, no theory of mind, or executive dysfunction? Solving the puzzle of pragmatic language disorders. Brain and Language, 85, 451-466. doi:10.1016/S0093-934X(03)00070-1

38.

Mary

Slama

Mousty

Massat

Capiau

Drabs

Peigneux

(2016). Executive and attentional contributions to Theory of Mind deficit in attention deficit/hyperactivity disorder (ADHD). Child Neuropsychology, 22, 345-365. doi:10.1080/09297049.2015.1012491

39.

Olderbak

Wilhelm

Olaru

Geiger

Brenneman

M. W.

Roberts

R. D.

(2015). A psychometric analysis of the reading the mind in the eyes test: Toward a brief form for research and applied settings. Frontiers in Psychology, 6, Article 1503. doi:10.3389/fpsyg.2015.01503

40.

Ornaghi

Brockmeier

Grazzani

(2014). Enhancing social cognition by training children in emotion understanding: A primary school study. Journal of Experimental Child Psychology, 119, 26-39. doi:10.1016/j.jecp.2013.10.005

41.

Parke

E. M.

Thaler

N. S.

Etcoff

L. M.

Allen

D. N.

(2020). Intellectual profiles in children with ADHD and comorbid learning and motor disorders. Journal of Attention Disorders, 24, 1227-1236. doi:10.1177/1087054715576343

42.

Pelc

Kornreich

Foisy

M. L.

Dan

(2006). Recognition of emotional facial expressions in attention-deficit hyperactivity disorder. Pediatric Neurology, 35, 93-97. doi:10.1016/j.pediatrneurol.2006.01.014

43.

Reynolds

C. R.

Kamphaus

R. W.

(2004). Behavior assessment system for children (2nd ed.). Upper Saddle River, NJ: Pearson Education.

44.

Ryan

N. P.

Catroppa

Beare

Coleman

Ditchfield

Crossley

. . . Anderson

V. A.

(2015). Predictors of longitudinal outcome and recovery of pragmatic language and its relation to externalizing behaviour after pediatric traumatic brain injury. Brain and Language, 142, 86-95. doi:10.1016/j.bandl.2015.01.007

45.

Schwenck

Schmitt

Sievers

Romanos

Warnke

Schneider

(2011). Cognitive and emotional empathy in children with ADHD and conduct disorder. Zeitschrift fur Kinder-und Jugendpsychiatrie und Psychotherapie, 39, 265-276. doi:10.1024/1422-4917/a000118

46.

Semrud-Clikeman

(2010). The role of inattention and social perception and performance in two subtypes of ADHD. Archives of Clinical Neuropsychology, 25, 771-780. doi:10.1093/arclin/acq074

47.

Shamay-Tsoory

S. G.

Aharon-Peretz

(2007). Dissociable prefrontal networks for cognitive and affective theory of mind: A lesion study. Neuropsychologia, 45, 3054-3067. doi:10.1016/j.neuropsychologia.2007.05.021

48.

Shamay-Tsoory

S. G.

Aharon-Peretz

Perry

(2009). Two systems for empathy: A double dissociation between emotional and cognitive empathy in inferior frontal gyrus versus ventromedial prefrontal lesions. Brain, 132, 617-627. doi:10.1093/brain/awn279

49.

Sinzig

Morsch

Lehmkuhl

(2008). Do hyperactivity, impulsivity and inattention have an impact on the ability of facial affect recognition in children with autism and ADHD? European Child & Adolescent Psychiatry, 17, 63-72. doi:10.1007/s00787-007-0637-9

50.

Sodian

Hülsken

(2005). The developmental relation of theory of mind and executive functions: A study of advanced theory of mind abilities in children with attention deficit hyperactivity disorder. In Schneider

Schumann-Hengsteler

Sodian

(Eds.), Young children’s cognitive development: Interrelationships among executive functioning, working memory, verbal ability, and theory of mind (pp. 175-187). Mahwah, NJ: Lawrence Erlbaum.

51.

Staikova

Gomes

Tartter

McCabe

Halperin

J. M.

(2013). Pragmatic deficits and social impairment in children with ADHD. Journal of Child and Psychology and Psychiatry, 54, 1275-1283. doi:10.1111/jcpp.12082

52.

Thaler

N. S.

Allen

D. N.

Sutton

G. P.

Vertinski

Ringdahl

E. N.

(2013). Differential impairment of social cognition factors in bipolar disorder with and without psychotic features and schizophrenia. Journal of Psychiatric Research, 47, 2005-2010. doi:10.1016/j.jpsychires.2013.09.010

53.

Thaler

N. S.

Sutton

G. P.

Allen

D. N.

(2014). Social cognition and functional capacity in bipolar disorder and schizophrenia. Psychiatry Research, 220, 309-314. doi:10.1016/j.psychres.2014.08.035

54.

Uekermann

Abdel-Hamid

Schimmelmann

B. G.

Hebebrand

Daum

Wiltfang

Kis

(2010). Social cognition in attention-deficit/hyperactivity disorder (ADHD). Neuroscience & Biobehavioral Reviews, 34, 734-743. doi:10.1016/j.neubiorev.2009.10.009

55.

Väisänen

Loukusa

Moilanen

Yliherva

(2014). Language and pragmatic profile in children with ADHD measured by Children’s Communication Checklist 2nd edition. Logopedics Phoniatrics Vocology, 39, 179-187. doi:10.3109/14015439.2013.784802

56.

Wechsler

(2014). Wechsler Intelligence Scale for Children (5th ed.). San Antonio, TX: Pearson.

57.

Williams

L. M.

Hermens

D. F.

Palmer

Kohn

Clarke

Keage

. . . Gordon

(2008). Misinterpreting emotional expressions in attention-deficit/hyperactivity disorder: Evidence for a neural marker and stimulant effects. Biological Psychiatry, 63, 917-926. doi:10.1016/j.biopsych.2007.11.022