ADHD and Theory of Mind in School-Age Children: Exploring the Cognitive Nature of Social Interactions in Children with ADHD

Children with Attention Deficit Hyperactivity Disorder (ADHD) experience significant difficulties with social skills (Barkley, 2006; DuPaul & Stoner, 2003; Stormont, 2001). The inhibitory deficit associated with ADHD is typically identified as the cause of these impaired social skills (Barkley, 2006). Additionally, some researchers have suggested that theory of mind (ToM), which is the ability to attribute mental states to oneself and to others, may be involved, but the research on ToM deficits in children with ADHD is limited and the findings are mixed. A key methodological issue in this literature is the use of traditional but problematic measures of advanced ToM. These measures either fail to find developmental changes or do not measure adaptive reasoning, which is more representative of how individuals behave in real social interactions (Hayward, Homer, & Sprung, 2016). The present investigation used a different tool called Flexibility and Automaticity of Social Cognition (FASC), a new measure of advanced ToM (Hayward et al., 2016), as well as the Strange Stories (SS) task to analyze the relation between ToM, ADHD, and social difficulties in children. Results indicated that children with ADHD did not differ in performance from controls on the SS task, or on the FASC dimensions of total responses (TRs), total mental state terms (MSTs), and First Common Response (FASCFCR). Participants in the ADHD group did demonstrated impairment relative to controls in the number of mental state justifications (MSJs) provided in the FASC. There was also a significant negative correlation between ADHD symptom count and FASC-FCR. Finally, the number of FASC-FCRs significantly correlated with social skills domains on the C3-PRS and the BASC-2PRS. The current findings suggest that social skills deficits in children with ADHD can partially be explained by difficulties with some aspects of ToM. ADHD AND THEORY OF MIND v Acknowledgments I have many people to thank for supporting me throughout my graduate school journey. First, I would like to thank my mentor, Dr. Bruce Homer. Dr. Homer has been an inspiring and motivating mentor. As his student I was fascinated with his field of research and unique perspective on education, technology and cognitive neuroscience. Dr. Homer saw my passion and took me on as his advisee. He supported my growth as a scientist and gave me the opportunity to participate in additional research projects and present at professional conventions. Finally, I could not have accomplished the cumbersome task of completing my dissertation without Dr. Homer’s support. I would also like to thank my committee members. Dr. Georgiana Tryon has been both a valuable professor and a committed mentor. Since I began graduate school Dr. Tryon has been my advocate. Her integrity, passion, and support have been unwavering. She has instilled in me a commitment to ethics, integrity, and compassion. Dr. Mario Kelly has been another vital supporter in this endeavor. In addition to being an inspiring professor, Dr. Kelly’s wit, energy, and positive attitude helped me succeed through difficult circumstances. As a result, I am now a stronger person and will continue to persevere in the face of adversity. I would like to express my gratitude to Dr. Elizabeth Hayward for her assistance and feedback throughout this research project. I would like to thank Dr. Sara Birch and Dr. Theresa Bhoopsingh for their support and camaraderie. Lastly, I would like to thank my family. I am grateful to my parents who have been my biggest advocates. I am grateful for their endless love, encouragement, and support. Finally, my deepest gratitude goes to my husband, Adam Deyong who has helped me relish the highs and endure the lows. Thank you, Adam, for always believing in me ADHD AND THEORY OF MIND vi TABLE OF CONTENTS Abstract . iv Acknowledgments.v Chapter 1: Introduction . 1 Study Objectives and Rationale . 4 Chapter 2: Literature Review . 6 Executive Functioning . 6 Inhibition . 8 Attention Deficit Hyperactivity Disorder . 12 Diagnosis and etiology of ADHD . 12 ADHD and language . 21 Theory of Mind . 22 The developmental relationship between ToM and EF . 23 The relationship between ToM and language development . 24 Social Skills Development and Dysfunction . 26 Theory of mind and social skills . 27 ADHD and social skills impairment . 30 Bridging ADHD, Theory of Mind, Executive Functioning, and Social Skills . 31 Current Study . 37 Chapter 3: Method . 39 Participants . 39 Measures . 40 Theory of Mind (ToM) . 40 ADHD AND THEORY OF MIND vii Behavior rating scales . 47 Executive Functioning (EF) . 50 Procedure . 52 Chapter 4: Results . 54 Descriptive Analyses . 54 Theory of Mind, Executive Functioning, and Behavior . 57 ADHD and ToM Impairment . 61 Exploratory Analyses on ToM, Social Skills, and ADHD . 63 Chapter 5: Discussion . 66 Summary of Findings . 66 ADHD and Theory of Mind Impairment . 66 ADHD and Social Skills Impairment . 69 ToM Performance and Social Skills . 71 Relationship Between ToM Performance and ADHD . 72 Limitations . 77 Implications and Future Research . 78 Conclusion . 81 Appendices . 83 FASC Cartoon Types and Prompts . 85 References . 90 ADHD AND THEORY OF MIND viii LIST OF TABLES AND FIGURES Table 1. Executive Inhibition Components and Definitions . 9 Table 2. DSM-IV-TD ADHD Diagnostic Criteria Symptoms . 14 Table 3. FASC Measures of Flexibility . 42 Table 4. Scoring of FASC Measures . 45 Table 5. Descriptive Statistics of FASC Flexibility by age group and cartoon type . 46 Table 6 Participants' Demographic Characteristics . 55 Table 7. Participants' Age and Clinical Characteristics . 56 Table 8. Correlations between Age,