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Empathy and Social Perspective Taking in Children

with Attention-Deficit/Hyperactivity Disorder


Imola Marton & Judith Wiener & Maria Rogers &
Chris Moore & Rosemary Tannock
Published online: 20 August 2008
# Springer Science + Business Media, LLC 2008
Abstract This study explored empathy and social perspec-
tive taking in 8 to 12 year old children with and without
Attention-Deficit/Hyperactivity Disorder (ADHD). The
sample comprised 92 children, 50 with a diagnosis of
ADHD and 42 typically developing comparison children.
Although children with ADHD were rated by their parents
as less empathic than children without ADHD, this
difference was accounted for by co-occurring oppositional
and conduct problems among children in the ADHD
sample. Children with ADHD used lower levels of social
perspective taking coordination in their definition of
problems, identification of feelings, and evaluation of
outcomes than children without ADHD, and these differ-
ences persisted after the role of language abilities, intelli-
gence and oppositional and conduct problems were taken
into account. Girls were more empathic and had higher
overall social perspective taking scores than boys. Implica-
tions for research and practice are discussed.
Keywords Attention-deficit/hyperactivity disorder
(ADHD)
.
Empathy
.
Social perspective taking
.
Language
.
Oppositional and conduct problems
Despite the well-documented socialbehavioral and peer
relationship problems of children with Attention-Deficit/
Hyperactivity Disorder (ADHD), the social-cognitive
mechanisms underlying these social difficulties remain
poorly understood (Hoza et al. 2005). Examining social-
cognitive characteristics such as empathy and social
perspective taking, however, may contribute critical infor-
mation in understanding why as many as 50% of children
with ADHD experience social difficulties (Landau et al.
1998). The current study compares empathy and social
perspective taking in 8 to 12 year old children with and
without ADHD and investigates potential predictors of
these variables in this clinical population.
Empathy and Social Perspective Taking
Social cognition is a broad term referring to the cognitive
mechanisms that individuals use to understand social
situations (Staub and Eisenberg 1981). The basic assump-
tion underlying social cognitive processes is that children
apply cognitive abilities to interpret social situations and
problem-solve in the social domain. Empathy and social
perspective taking are the two aspects of social cognition
examined in this study.
Barkley (2006) argued that the behavioral inhibition
deficits of children with ADHD impair their abilities in
various social-cognitive domains. He predicted that these
children would show less empathy and a reduced ability to
take the perspective of another person due to their deficits
in neurologically based (prefrontal) inhibitory control.
According to this theory, self-regulatory skills are a
prerequisite to perspective taking and empathy because
children need to inhibit responses long enough to consider
that someone elses perspective may differ from their own
J Abnorm Child Psychol (2009) 37:107118
DOI 10.1007/s10802-008-9262-4
This research was funded by the Social Sciences and Humanities
Research Council (SSHRC).
I. Marton (*)
:
J. Wiener
:
M. Rogers
:
R. Tannock
Department of Human Development and Applied Psychology,
Ontario Institute for Studies in Education (OISE),
University of Toronto,
252 Bloor Street West, 9th Floor,
Toronto, Ontario, Canada M5S 1V6
e-mail: imarton@oise.utoronto.ca
C. Moore
Department of Psychology, Dalhousie University,
Halifax, Nova Scotia, Canada
and to understand the emotional experience of another
person. Other researchers have argued that ADHD involves
the disruption not only of behavioral inhibition, but
multiple components of the self-regulatory system, includ-
ing various aspects of executive functioning (Nigg et al.
2005), skills that underlie and regulate social-cognitive
processing (Schneider et al. 2005).
Empathy is an affective response that stems from the
apprehension or comprehension of another persons emo-
tional state or condition, and that is very similar or identical
to the other persons feeling (Eisenberg et al. 2006). This
social-cognitive ability has long been implicated in the
development of prosocial behaviors (e.g. Hoffman 2000).
The two studies to date that examined empathy in children
with ADHD have reported that these children were less
empathic than comparison children (Braaten and Rosen
2000; Dyck et al. 2001). Dyck et al. (2001) assessed 9 to
16 year old childrens ability to define emotion words,
recognize facial expressions and understand the emotional
consequences of exposure to a given situation. Braaten and
Rosen (2000) assessed empathy in 6 to 13 year-old boys
using narratives accompanied by pictures and found that
boys with ADHD were less likely to match the emotion
they identified in a story character with one identified in
themselves. Although picture-story measures can be useful
in assessing state empathy in young children, there has been
concern about their psychometric properties (Eisenberg and
Miller 1987) because stories are typically too short to
induce sufficient affect to evoke empathy and using longer
stories has not been shown to improve the validity of the
measure. Thus, assessment of childrens empathy using
picture-story measures are not related to spontaneous
prosocial behavior (Eisenberg-Berg and Lennon 1980).
The current study extends existing research regarding
empathy in children with ADHD primarily by assessing
empathy as a trait through self- and parent-report and by
considering the role of Oppositional and Conduct Problems
(CP) in empathy.
Questionnaires assessing the trait of empathy have the
benefit of tapping empathetic and sympathetic reactions
over a broad range of behaviors and situations; thus
questionnaires are more likely to provide a stable and
consistent estimate of empathic responding than measures
pertaining to specific narratives (Eisenberg and Miller
1987). Given their validity, questionnaire measures of
empathy have consistently been shown to be negatively
related to aggression and positively related to prosocial
behaviors (Eisenberg and Fabes 1998; Eisenberg and Miller
1987).
Although the rate of comorbidity between ADHD and
Oppositional Defiant Disorder (ODD) and Conduct Dis-
orders (CD) is 3040% (Gresham et al. 2005), and
aggressive tendencies are negatively related to empathy in
children older than 6 years of age (Hastings et al. 2000), the
existing studies examining empathy in children with
ADHD did not investigate the extent to which variability
in CP may have been related to empathy (Braaten and
Rosen 2000; Dyck et al. 2001). Therefore, it is not known
whether children with ADHD exhibit lower levels of
empathy independent of CP.
Social perspective taking (SPT) is the ability to
understand a social situation from another persons per-
spective (Selman 1971). Selman (2003) argued that the
ability to understand and coordinate ones own perspective
with that of another person is a fundamental determinant of
moral and social development in children. In support of this
claim, perceptual, affective and cognitive perspective taking
skills have all been shown to be positively related to
prosocial behavior in the general population (Underwood
and Moore 1982). To our knowledge, no studies have
examined SPT in children diagnosed with ADHD. Cohen et
al. (1985) found that children scoring high on hyperactivity
and aggression exhibited less developed SPT on the
Chandler Social Perspective Taking Task than a clinical
sample of internalizing children. Other studies examining
the SPT skills of children with oppositional, conduct and
aggressive behaviors have also reported lower levels of
SPT among chronically delinquent boys (Chandler 1973;
Chandler et al. 1974).
Given the high comorbidity between ADHD and other
behavioral problems, it is important to clarify the indepen-
dent effect of CP and ADHD on SPT performance. Due to
their problems with social skills and peer relationships
(Greene et al. 1996; Hoza et al. 2005), it is plausible that
both children with ADHD and CP may have deficits in
SPT, but due to different mechanisms. For example, it is
possible that the hostile attribution bias that characterize
children with CP creates strained social relationships, which
in turn results in fewer opportunities to practice their SPT
and social skills. Children with ADHD may have similarly
strained social relationships, in part because their behavior-
al inhibition and broader executive functioning deficits may
cause them to act without taking time to process social
information, or consider the thoughts and feelings of those
around them.
In addition to considering the role of comorbid CP in
SPT, examining the role of intelligence and language is
important because most measures of SPT demand cognitive
reasoning and language abilities and children with ADHD
have been shown to have less developed skills in both of
these domains (Kovac et al. 2001; Kuntsi et al. 2004).
Although children with ADHD demonstrate less advanced
narrative skills (Renz et al. 2003) than typically developing
children, none of the existing studies examining SPT in
children with ADHD-like symptoms have included a
comprehensive measure of language. Cohen et al. (1998),
108 J Abnorm Child Psychol (2009) 37:107118
however, examined SPT in children with language impair-
ments and various other psychiatric disorders using the
Interpersonal Negotiation Strategies measure (INS; Schultz
et al. 1989). Forty-three percent of the sample was
comprised of children diagnosed with ADHD and 40%
with ODD. Children with language impairment generated
lower levels of SPT skills than a psychiatric comparison
sample. However, because there was a higher proportion of
children with comorbid ADHD in the language impaired
group, it is unknown whether language impairments
interacted with ADHD symptoms to compromise these
childrens performance on the INS. In fact, all psychiatri-
cally referred children exhibited less developed SPT than
would be expected for their age (Cohen et al. 1998).
Objectives and Hypotheses
The current study was guided by two key objectives. The
first objective was to compare children with and without
ADHD on measures of empathy and SPT. It was hypothe-
sized that children with ADHD would be less empathic and
demonstrate lower levels of SPT than comparison children.
The second objective was to examine whether ADHD status
predicted variance in empathy and SPT above difficulties
that are common in children with ADHD and have been
previously shown to be related to these social-cognitive
factors. Given the well-established relationship between
empathy and externalizing behaviors (e.g. Hastings et al.
2000), it was hypothesized that ADHD status would not
explain variance in empathy once the effects of CP are
considered. Given that executive functioning skills are
required for SPT (Schneider et al. 2005) and that children
with ADHD exhibit deficits in many aspects of executive
functioning (Nigg et al. 2005), it was hypothesized that
ADHD status would predict SPT beyond variability
explained by intelligence, language and CP. Language and
intelligence were investigated as predictors of SPT but not
empathy because previous research shows these skills are
related to SPT (e.g. Astington and Baird 2005; Yeates et al.
1990), while this is not the case for empathy. Furthermore
the SPT measure used in this study demands cognitive
reasoning and language skills, but the empathy measure has
minimal cognitive and language demands.
Method
Participants
The sample consisted of 92 children (66 boys, 26 girls)
between the ages of 8 to 12 years. Fifty children had a
diagnosis of ADHD (36 male, 14 female) and 42 were
comparison children without behavior problems (30 male,
12 female). Children with a standard score below 80 on
standardized measures of intellectual functioning were
excluded from analysis. Children with ADHD were referred
from two local hospital clinics and from the community
through posters at various childrens mental health centres.
Children without ADHD were recruited from local schools,
newspaper advertisements and through posters in the
community.
For inclusion in the ADHD sample, participants were
required to have a previous diagnosis of ADHD, according
to DSM-IV criteria from a physician or a mental health
professional. In order to ensure that symptoms were
currently present, parents and teachers were asked to
complete the Conners Parent or Teacher Rating Scale-
Revised (CPRS/CTRS; Conners 1997). ADHD symptom-
atology was confirmed if the participant was rated within
the clinical range (T Score70) by one informant and
within the borderline (T Score65) or clinical range by the
second informant on the DSM-IV-oriented ADHD sub-
scales of the CPRS and the CTRS. For children taking
psychostimulant medication, parents and teachers were
asked to think of the child off medication when completing
the questionnaires. For inclusion in the comparison sample,
participating children were required to have no previous or
current diagnosis of ADHD or other behavioral disorder.
Parents and teachers were asked to complete the CPRS/
CTRS to ensure that children in the comparison group did
not display a significant number of ADHD symptoms.
Children in the comparison group who received a T-score
below 65 on all three DSM-IV ADHD subscales on both
the CPRS and CTRS were included in the sample.
At the time of data collection, 24 participants (48%) with
ADHD were taking psychostimulant medication and 27
(54%) had at least one comorbid diagnosis from a mental
health professional (11 Learning Disabilities, 11 Anxiety
Disorder, 10 Oppositional Defiant Disorder, 4 Mood
Disorder). Chi-square tests were computed to determine if
there were any demographic differences between children
with and without ADHD. These analyses revealed no
significant differences in gender
2
(1, N=92)=0.004 p=
0.95, languages spoken in the home (English or other,
2
(1,
N=92)=1.640, p=0.20), or parent marital status
2
(1, N=
92)=3.608, p=0.06. A series of independent samples t-tests
were conducted to examine ADHD status differences in
age, socio-economic status (SES) measured using parent
level of education, IQ, language, ADHD symptoms and
oppositional and conduct behaviors (Table 1). The samples
of children with and without ADHD did not differ on age.
Parents in the comparison sample generally attained higher
levels of education than parents of children with ADHD.
Children with ADHD scored lower on standardized
measures of intelligence and language and attained higher
scores on all of the DSM ADHD scales of the CPRS and
J Abnorm Child Psychol (2009) 37:107118 109 109
CTRS and on the Oppositional and Conduct Problems
scales of the Child Behavior Checklist (CBCL; Achenbach
2001) than comparison children. Given the strong
positive correlation between the Oppositional and Con-
duct Problems T-scores of the CBCL (r=0.795, p<0.001),
they were averaged for further analysis and called the CP
composite.
Measures
The Conners Parent and Teacher Rating Scales Revised:
Long Form (CPRS-R:L and CTRS-R:L; Conners 1997) are
well-established measures that assess problem behaviors.
Parents and teachers rate childrens behavior on a four-point
scale ranging from not true at all to very much true.
The three DSM-IV ADHD subscales (i.e., DSM-IV:
Inattentive, DSM-IV: HyperactiveImpulsive, DSM-IV:
Total) were utilized in this study. The CPRS and CTRS
are frequently used in research and have good psychometric
properties (Conners 1997).
The Child Behavior Checklist (CBCL; Achenbach 2001)
is a well-established standardized questionnaire for parents
to report the frequency and intensity of behavioral and
emotional problems exhibited by their children. Parents rate
their childrens behavior on 113 items that range from not
true to very true. The DSM-IV Oppositional and
Conduct Problems subscales of the CBCL were used for
analysis. These subscales have good psychometric proper-
ties (Cronbachs alpha=0.86 and 0.91 and testretest
reliability=0.85 and 0.93, respectively) and are commonly
used in research.
Wechsler Intelligence Scale for ChildrenFourth Edition
(WISC-IV; Wechsler 2003) and Wechsler Abbreviated Scale
of Intelligence (WASI; Wechsler 1999). Clinic-referred
children with ADHD (44% of the sample) were administered
the WISC-IVas part of a complete psychological assessment.
Community-referred children with ADHD (56% of the
sample) and all children in the comparison sample were
administered the WASI, a screening measure of overall
intelligence in children (Sattler 2001). Both the WISC-IV
and the WASI are commonly used intelligence measures for
children with good reliability, testretest stability and
construct validity (Wechsler 2003; Sattler 2001). The full-
scale scores from the WISC-IV and WASI were used for
analyses.
The Clinical Evaluation of Language Fundamentals
(CELF-4; Semel et al. 2003) is a standardized measure
used for identifying language difficulties in children. The
test generates a Core Language scale, which was used as a
measure of overall language abilities in the analyses. The
psychometric properties of the CELF-4 are well established
with stability coefficients ranging from 0.900.93, internal
consistency from 0.930.95 for children between 812 years
of age, and factor analysis demonstrating construct validity
(Semel et al. 2003).
The Index of Empathy for Children and Adolescents
(Bryant 1982) is a measure developed to assess empathy in
children 6 years and older. The scale taps a variety of
childrens emotional reactions, including susceptibility to
emotional contagion, understanding the feelings of familiar
and unfamiliar people, emotional responsiveness to others
emotions, and feelings of sympathy towards others. The
scale consists of 22 dichotomous (true/false) items such as:
It makes me sad to see a boy who cant find anyone he can
play with. The measure is scored by assigning each yes
response a score of 1 and no response a score of 0 (except
Table 1 Demographic Characteristics of ADHD and Non-ADHD Participants
ADHD (n=50) Comparison (n=42) t (df) p
M (SD) M (SD)
Age 10.08 (1.39) 10.20 (1.46) 0.40 (90) 0.690
SES 7.76 (1.79) 9.02 (1.15) 4.07 (85) 0.000
IQ 103.64 (12.81) 112.00 (12.49) 3.15 (90) 0.002
Core language 103.20 (10.36) 112.19 (10.49) 4.12 (90) 0.000
CPRSinattentive 75.64 (9.81) 45.64 (5.20) 18.70 (77) 0.000
CPRShyp/imp 77.00 (10.71) 47.67 (4.80) 17.39 (70) 0.000
CPRStotal 78.12 (7.84) 46.26 (5.05) 23.50 (84) 0.000
CTRSinattentive 68.88 (11.52) 49.12 (6.18) 10.38 (76) 0.000
CTRShyp/imp 69.33 (12.78) 48.48 (6.64) 9.95 (74) 0.000
CTRStotal 70.78 (11.58) 48.90 (5.80) 11.62 (73) 0.000
CBCL oppositional 64.46 (8.32) 52.98 (4.12) 8.58 (74) 0.000
CBCL conduct 63.52 (8.17) 51.83 (3.09) 9.34 (65) 0.000
Age = in years; SES = highest education of mother or father; IQ = standard score of overall WISC-IVor WASI; Core language = standard score of
core language scale of the CELF-4; CPRS = DSM-IV: inattentive, hyperactiveimpulsive and total scores of the parent Conners; CTRS = DSM-
IV: inattentive, hyperactiveimpulsive and total scores of the teacher Conners; CBCL oppositional = standard score of CBCL Oppositional
Problems; CBCL Conduct = standard score of CBCL conduct problems scale
110 J Abnorm Child Psychol (2009) 37:107118
for reverse-scored items). Therefore, higher scores imply
more empathy. This measure was found to have adequate
internal consistency in the current sample (Cronbachs
alpha=0.70). In a standardization sample, Bryant (1982)
reported a Cronbachs alpha of 0.68 for fourth graders and
0.79 for seventh graders. Testretest reliability coefficients
were 0.81 for fourth graders and 0.83 for seventh graders.
Convergent validity with existing measures of empathy was
attained for the total sample for each grade (Bryant 1982).
Gender and developmental analyses indicated that older
children and girls were more empathic than younger
children and boys (Bryant 1982).
My Child is a parent questionnaire that was developed
to assess childrens empathy (Kochanska 1992). Thirteen
items on this scale comprise the Empathy subscale, which
assesses prosocial responses to anothers distress and
empathy (e.g. Will try to comfort or reassure another in
distress). Parents rated their childrens empathy on a
seven-point scale ranging from 0 (extremely untrue) to 7
(extremely true). Higher scores imply more empathy.
Internal consistency for the Empathy subscale was
reported to be 0.80 in a general population sample and
the measure was moderately related to assessments of
childrens moral behavior in a laboratory setting
(Kochanska DeVet et al. 1994). The measure was found
to have adequate internal consistency in the current sample
(Cronbach alpha=0.76).
The Interpersonal Negotiation Strategies (INS; Schultz
et al. 1989) is a structured interview designed to assess
childrens ability to coordinate social perspectives through
interpersonal negotiation. The childrens version, appropri-
ate for children 712 years, consists of 12 hypothetical
social dilemmas with a series of standard questions and
follow-up probes. According to standard procedure, four of
the 12 dilemmas were administered, two assessing inter-
personal negotiation between friends and two between
acquaintances. The dilemmas portray interpersonal conflict
between a protagonist and a significant other in
situations that are assumed to create inner disequilibrium
within the protagonist. The questions in the structured
interview were designed to provide a measure of childrens
SPT through their use of the following five functional
problem-solving steps: Definition of the Problem, Identifi-
cation of Feelings, Alternative Strategies, Selecting the Best
Strategy, and Evaluating Outcomes.
The INS was adapted for the purposes of this study.
Because children with ADHD have working memory
difficulties (e.g. Martinussen et al. 2004), pictures were
drawn to accompany the written INS dilemmas to
facilitate recall. In addition, pilot testing revealed that
children found the INS lengthy in the context of a large
battery of additional measures; thus questions 5 to 7 of
the original INS protocol, which involved evaluating
various problem-solving options, were omitted. In one-to-
one administration children were first given the standard
instructions about the task as outlined in the INS manual.
Next, each dilemma was read by the examiner while the
child looked at the accompanying picture and text.
Children were then asked the series of problem-solving
questions. Responses were transcribed and later scored by
a graduate student blind to the group status of the child
using the scoring guidelines outlined in the INS manual.
SPT coordination reflects the extent to which children are
able to integrate and coordinate the thoughts, feelings
and intentions of both the protagonist and the other
character. The levels of the scores are: 0impulsive,
without consideration of perspectives; 1unilateral, con-
sideration of only one persons perspective; 2recipro-
cal, each persons perspective expressed separately; 3
collaborative, mutuality expressed in the coordination of
both persons perspectives. The scores for each problem-
solving step were averaged across the four dilemmas to
yield an estimate of developmental level for each step.
The average scores for all problem-solving steps across
the dilemmas were then summed and divided by 4 (the
number of dilemmas) to yield an overall measure of SPT
coordination (Total INS). Therefore, scores for all
problem-solving steps and the Total INS range from 0
to 3, with lower scores representing lower levels of SPT
coordination.
Because each dilemma involves a protagonist, two
subscales (Generating Alternative Strategies and Selecting
the Best Strategy) can also be scored for Interpersonal
Orientation, which reflects different ways of exercising
control over and regulating social interaction. Orientation
can be scored as Self-Transforming (strategies that relegate
the protagonists needs to a position of secondary impor-
tance relative to the others needs), Other-Transforming
(strategies that assert the primacy of the selfs needs over
those of the other), Collaborative (strategies that attempt to
balance the needs of both self and other through an
integration of orientations that considers the perspectives
of both equally), and Indeterminate (strategies that are not
collaborative and are not clearly either self- or other-
transforming). The type of interpersonal orientation across
the four dilemmas was summed.
The validity of the INS model as a developmental
paradigm was supported by a number of studies conducted
by Selman and colleagues, indicating that children demon-
strate more advanced levels of SPT with development (e.g.
Selman et al. 1986; Yeates et al. 1991). Interrater reliability
of the INS scores has been reported to range between 0.62
and 0.96, and a testretest reliability score of 0.69 was
reported across a 4-month interval (Selman et al. 1986;
Yeates et al. 1991). In the current study, reliability checks
were made on 30% of the protocols, and interrater reliability
J Abnorm Child Psychol (2009) 37:107118 111 111
was 0.86 using weighted linear kappa for SPTand 0.92 using
unweighted kappa for interpersonal orientation. The level of
SPT was also found to have good internal consistency in the
current sample (Cronbach alpha=0.83). Research indicates
that the INS measures a distinct domain apart from IQ and
demonstrates adequate internal and external validity (Enright
and Lapsley 1980; Yeates et al. 1991). The INS has been
reported to correlate with indices of social status (r=0.58 for
girls and 0.66 for boys) and behavior problems (r=0.17 for
girls and 0.33 for boys) (Yeates et al. 1991). In addition, a
correlation of 0.38 was reported between performance on the
INS and childrens actual behaviors as rated by their teachers
(Yeates et al. 1991).
Procedure
This research was conducted at three sites in Toronto,
Canada: the University of Toronto, the Hospital for Sick
Children and the Centre for Addiction and Mental
Health. During an initial screening, parents provided
demographic and medical information about their child
and family and completed the CPRS. Parents whose
children met screening criteria were scheduled for an
assessment. All children were tested individually by one
of two senior doctoral level students trained in clinical
child psychology. Assessments at the hospitals were
completed over two approximately 5-h testing sessions
and assessments completed at the University of Toronto
were conducted in one 5-h session. Children with ADHD
were medication free on the day that they completed the
research measures. While children were being tested,
parents completed questionnaires in the waiting room.
Once consent was obtained, teachers were sent the CTRS
to complete. Families received a written educational and
socialemotional report outlining their childs functioning
and children received a small toy of their choice for
participating.
Results
Preliminary Analyses
Preliminary analyses indicated that the correlations between
SES and Child Empathy (r=0.13, p=0.20), Parent
Empathy (r=0.18, p=0.08), and SPT (r=0.17, p=0.10)
were not significant; therefore, SES was not considered in
further analyses. Although group differences were detected
on other measures in this sample (IQ, oppositional and
conduct problems and language; see Table 1), these
variables were not covaried because they reflect attributes
that are commonly associated with ADHD (Gresham et al.
2005; Kovac et al. 2001; Kuntsi et al. 2004). Miller and
Chapman (2001) argued that controlling for pre-existing
group differences in a nonrandom research design violates
the core assumption of analysis of covariance that cova-
riates are statistically independent from the grouping
variable.
Objective 1: Group Differences in Empathy and Social
Perspective Taking
The first set of analyses examined ADHD status and
Gender differences on measures of Empathy and SPT
(Table 2). The 22 analysis of variance with Parent-
Reported Empathy as the dependent variable indicated that
children with ADHD were rated as less empathic by their
parents, F (1, 86)=8.60, p<0.01, partial
2
=0.09, and boys
were rated as less empathic than girls, F (1, 86)=5.26, p<
0.05, partial
2
=0.06. There was no ADHD status by
Gender interaction effect, F (1, 86)=0.22, p=0.63, partial

2
=0.00. A 22 analysis of variance with Child-Reported
Empathy as the dependent variable indicated that girls rated
themselves to be more empathic than boys, F (1, 88)=
35.11, p<0.001, partial
2
=0.29. No main effect was found
for ADHD status, F(1, 88)=0.00, p=0.96,
2
=0.00 and
Table 2 Univariate Analysis of Social Perspective Taking and Child and Parent Empathy by ADHD Status and Gender
ADHD Total Comparison Total ADHD status Gender ADHD status
gender
Male Female Male Female
M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD)
Parent
empathy
68.49 (8.97) 72.00 (10.60) 69.43 (9.46) 73.23 (6.89) 78.58 (5.24) 74.76 (6.85) 8.60** (0.09) 5.26* (0.06) 0.22 (0.00)
Child
empathy
11.66 (3.17) 15.92 (2.20) 12.86 (3.49) 11.53 (3.54) 16.00 (3.07) 12.80 (3.95) 0.002 (0.00) 35.11** (0.29) 0.01 (0.00)
INS total 1.72 (0.33) 1.91 (0.29) 1.77 (0.32) 2.06 (0.29) 2.16 (0.20) 2.08 (0.27) 16.75** (0.16) 4.00* (0.04) 0.36 (0.00)
Parent empathy = parent-reported empathy on My Child; child empathy = child-reported empathy on the Index of Empathy for Children and
Adolescents; INS total is the total score on the Interpersonal Negotiation Strategies
INS Interpersonal negotiation strategies
*p<0.05;**p<0.01;***p<0.001
112 J Abnorm Child Psychol (2009) 37:107118
there was no ADHD status by Gender interaction effect, F
(1, 88)=0.01, p=0.89,
2
=0.00.
A 2 (ADHD status)2 (Gender) analysis of variance was
conducted to examine main and interaction effects on the
Total INS scale. As indicated in Table 2, children with
ADHD had less developed SPT skills overall than children
without ADHD, F(1, 86)=16.75, p<0.001,
2
=0.16 and
boys attained lower overall SPT scores than girls, F(1, 86)=
4.00, p<0.05,
2
=0.05. There was no ADHD status by
Gender interaction effect, F(1, 86)=0.36, p=0.54,
2
=0.00.
Analyses were also conducted on the five INS problem-
solving subscales. First, a two-way MANOVAwith the five
INS problem-solving subscales as dependent variables, and
ADHD status and Gender as the fixed factors were used to
examine differences in SPT. A significant multivariate
effect was detected for ADHD status, Wilkss =0.62, F
(5, 82)=9.87, p<0.001,
2
=0.37, but not for Gender,
Wilkss =0.92, F(5, 82)=1.32, p=0.26,
2
=0.07 and
there was no Gender by ADHD status interaction effect,
Wilkss =0.91, F(5, 82)=1.56, p=0.17,
2
=0.08. Using
the Bonferroni method, univariate ANOVAs for each
subscale of the INS were tested at the 0.01 level. As
indicated in Table 3, children with ADHD used less
advanced SPT in their Definition of the Problem, Identifi-
cation of Feelings and Evaluation of the Outcome than
comparison children. Children with and without ADHD did
not differ on their level of SPT when Selecting the Best
Strategy or when an average was taken of all of their
Alternative Strategies.
Independent samples t-tests were conducted to compare
children with and without ADHD on the number of
Alternative Strategies generated and the type of Interper-
sonal Orientation used to solve social dilemmas. As
indicated in Table 4, when asked to generate as many
strategies as possible to solve social dilemmas, children
with ADHD generated fewer ways to solve problems than
comparison children. Independent samples t-tests were used
to examine ADHD status differences in Interpersonal
Orientation on the Alternative Strategies and Selecting the
Best Strategy subscales. Children with ADHD used fewer
self-transforming and collaborative strategies than compar-
ison children when generating alternative strategies to
problem-solving. There were no group differences, howev-
er on the number of indeterminate and other-transforming
strategies in Alternative Strategies or on any of the
Interpersonal Orientation methods in Selecting the Best
Strategy.
Objective 2: Predictors of Empathy and Social Perspective
Taking
As previously mentioned, variables theoretically related to
each social-cognitive factor were considered in the analy-
ses. Because previous research has documented a relation-
ship between CP and empathy, and because CP is
frequently comorbid with ADHD, we examined whether
ADHD status predicted empathy above CP. Parent-
Reported Empathy was negatively correlated with both
CP (r=0.37, p<0.001) and ADHD status (r=0.30, p<
0.01). Because language and IQ have not been theoretically
related to empathy and were not correlated with empathy in
the current sample (r=0.11, p=0.27 and r=0.03, p=0.72,
respectively) they were not included in the regression
analysis. As indicated by the hierarchical regression
analysis shown in Table 5, when CP was entered first in
the regression it explained 14% of the variance in Parent-
Reported Empathy, R
2
=0.14, F (1, 88)=14.01, p<0.001;
ADHD status did not explain additional variance, R
2
change=0.00, F (1, 87)=0.30, p=0.58.
Previous research has shown that SPT is related to IQ,
language, and CP. In this sample, language and IQ were
positively correlated with SPT (r=0.42, p<0.001 and
r=0.39, p<0.001, respectively), and CP was negatively
correlated with SPT (r=0.27, p<0.01). Given these
relationships and that children with ADHD in the current
sample also demonstrated weaker IQ and language skills
and were rated to have higher levels of CP (Table 1), a
hierarchical regression was conducted to determine whether
ADHD status explained unique variance in SPT above
variance accounted for by language, IQ and CP (Table 5).
The order of the predictors was determined based on
previous research findings. Because the INS is a narrative
task that requires receptive and expressive language skills,
language was entered as the first predictor and it explained
Table 3 Multivariate Analysis
on the Interpersonal
Negotiations Strategies
Subscales by ADHD Status
INS Interpersonal negotiation
strategies
ADHD (n=48) Comparison (n=50) F p
2
M (SD) M (SD)
Social perspective taking (INS) subscales
Definition of problem 1.60 (0.35) 2.02 (0.31) 30.60 0.000 0.262
Identification of feelings 1.57 (0.39) 1.99 (0.48) 22.49 0.000 0.207
Alternative strategies 1.97 (0.34) 2.07 (0.34) 0.15 0.700 0.002
Selecting best strategy 2.06 (0.40) 2.26 (0.41) 2.27 0.135 0.026
Evaluating outcome 1.48 (0.64) 2.00 (0.50) 14.98 0.000 0.148
J Abnorm Child Psychol (2009) 37:107118 113 113
18% of the variance in SPT, R
2
=0.18, F(1, 88)=18.91, p<
0.001. As intelligence has also been strongly related to SPT,
it was entered next in the regression and it explained an
additional 4% of the variance, R
2
change=0.04, F(1, 87)=
3.99, p<0.05. Because CP has not been as strongly related
to SPT as language and IQ, it was entered in step 3 of the
regression but it did not explain additional variance in SPT,
R
2
change=0.02, F(1, 86)=2.18, p=0.14. To examine the
unique variance associated with ADHD status, it was
entered last in the regression, and it explained an additional
8% of the variance in SPT, R
2
change=0.08, F(1, 85)=9.53,
p<0.01, even after variance attributed to language, IQ and
CP in SPT was considered.
Discussion
Empathy
The goals of the current study were to establish whether
children with ADHD were less empathic than comparison
children and to examine the extent to which ADHD status
predicted empathy after variability associated with CP was
addressed. Although there was no difference between
ADHD and comparison children in self-reported empathy,
children with ADHD were rated as less empathic by their
parents. It is possible that children experience more
empathy internally than they exhibit behaviorally, making
it difficult for their parents to detect their affect. Conversely,
as found in previous studies, it is possible that childrens
ratings of empathy on self-report questionnaires in the
current sample was influenced by social desirability effects
(Eisenberg et al. 1991). Aggressive children (Hymel et al.
1993) and children with ADHD have been shown to
significantly overestimate their own competencies in
various areas of functioning, including academic, behav-
ioral and social domains (e.g. Hoza et al. 2004; Owens and
Hoza 2003). This positive illusory bias may serve a self-
protective function that counterbalances feelings of inade-
quacy among children, especially those with difficulties
(Diener and Milich 1997).
The finding in the current study that parents report
children with ADHD to exhibit lower levels of empathy is
consistent with existing studies (Braaten and Rosen 2000;
Dyck et al. 2001) using different methods of assessing
empathy in children with ADHD. Together, the results of
these studies suggest that children with ADHD demonstrate
less state empathy (i.e. picture-story measure, facial cues,
etc.), and exhibit behaviors that are perceived to be less
empathic by their parents. Parent-reported empathy was
used to further examine the role of CP and ADHD status in
empathy to avoid the potential confound of the positive
illusory bias commonly reported among this population.
Table 4 Independent Samples
t-tests for Children with and
without ADHD on the Number
of Alternative Strategies and
the Interpersonal Orientation of
Alternative Strategies and
Selecting the Best Strategy
a
Levenes test for equality of
variances was significant for #
of alternative strategies and #
of self-transforming strategies,
therefore scores for equality of
variances not assumed are
reported
ADHD Comparison t (df) p
M (SD) M (SD)
# Alternative strategies
a
7.77 (2.39) 9.60 (3.56) 2.80 (70) 0.007
Alternative strategies
# of indeterminate 3.50 (2.07) 3.60 (1.86) 0.22 (88) 0.820
# of self-transforming
a
0.88 (0.86) 1.40 (1.06) 2.57 (79) 0.012
# of other-transforming 2.13 (1.04) 2.60 (1.43) 1.79 (88) 0.076
# of collaborative 1.27 (1.08) 2.00 (1.46) 2.70 (88) 0.008
Selecting best strategy
# of indeterminate 1.54 (0.74) 1.33 (0.68) 1.37 (88) 0.173
# of self-transforming 0.19 (0.53) 0.19 (0.45) 0.02 (88) 0.977
# of other-transforming 1.21 (0.71) 1.10 (0.90) 0.66 (88) 0.510
# of collaborative 1.06 (0.83) 1.38 (0.98) 1.65 (88) 0.101
Table 5 Hierarchical Linear Regressions with CP and ADHD Status
as Predictors of Parent-Reported Empathy and Language, IQ, CP and
ADHD Status as Predictors of Social Perspective Taking
Parent-reported empathy
Variable B SE (B)
Step 1 Conduct problems 0.389 0.104 0.371***
Step 2 Conduct problems 0.328 0.151 0.313*
ADHD status 1.388 2.504 0.080
Social perspective taking
Step 1 Core language (CELF-4) 0.013 0.003 0.421***
Step 2 Core language (CELF-4) 0.009 0.003 0.291*
IQ 0.006 0.003 0.230*
Step 3 Core language (CELF-4) 0.007 0.004 0.235*
IQ 0.006 0.003 0.236*
Conduct problems 0.006 0.004 0.149
Step 4 Core language (CELF-4) 0.006 0.003 0.205
IQ 0.005 0.003 0.176
Conduct problems 0.005 0.005 0.110
ADHD status 0.274 0.089 0.403**
Predicting parent-reported empathy: R
2
=0.14 for Step 1; R
2
=0.00
for Step 2. Predicting SPT: R
2
=0.18 for Step 1; R
2
=0.04 for Step 2;
R
2
=0.02 for Step 3; R
2
=0.08 for Step 4
*p<0.05; **p<0.01; ***p<0.001
114 J Abnorm Child Psychol (2009) 37:107118
ADHD diagnosis, however, did not explain additional
variance in empathy once CP was accounted for. This
suggests that children with ADHD who have clinical levels
of CP are at increased risk of deficits in empathy, but
children with ADHD who do not have clinical levels of
these behaviors exhibit similar levels of empathy to
comparison children. This finding is in accordance with
various other studies indicating that children with aggres-
sive behaviors exhibit lower levels of empathy than
children who are not aggressive (e.g. de Wied et al.
2005), and comorbid ADHD does not contribute variance
in explaining lack of empathy in children with conduct
problems (Enebrink et al. 2005). These findings also
highlight that it is critical to consider comorbid CP when
examining empathy in clinical populations.
Consistent with the existing research, in the current
study girls were more empathic than boys according to self-
and parent-ratings (Karniol et al. 1998; Olweus and
Endresen 1998). Eisenberg and Lennon (1983) found that
self-report measures of empathy evoke demand character-
istics; children may become aware that empathy is being
assessed and attempt to provide responses in line with
prevailing gender stereotypes. As such, girls may rate
themselves more favorably than boys as a means of
adhering to gender-specific conceptions. On the other hand,
it is possible that girls do in fact exhibit more empathy,
perhaps because empathic tendencies are better fostered and
reinforced during the socialization of girls than boys (e.g.,
mothers engage in more emotion talk with girls; Cervantes
and Callanan 1998). Research shows that girls exhibit more
empathy as assessed through various methods, such as
evocative films, slides and puppet shows, observational
measures of empathy and parent and teacher reports (e.g.,
Eisenberg and Fabes 1998; Strayer and Roberts 1997).
Social Perspective Taking
A major goal of this study was to examine whether children
with and without ADHD differ in their SPT ability, and
whether variability in language ability, IQ and CP predicted
SPT skills. Our results build on the Cohen et al. (1985)
findings by demonstrating that children formally diagnosed
with ADHD have poorer overall SPT skills than children
without ADHD. They employed less advanced SPT at
various problem-solving stages. Although formal age
norms do not exist for the interview, scores between 2
and 3 would be expected for children in the age range of
this study (Cohen et al. 1998). In the current sample,
average scores for children in the comparison sample fell in
the age-appropriate range, whereas children with ADHD
typically attained lower scores than would be expected for
their age. This suggests that they are less likely to take
multiple perspectives and coordinate perspectives than is
typical of children their age. Because understanding another
persons thoughts and feelings facilitates other-oriented
processes and behaviors, including sympathy, sharing,
comforting, and helping, all skills that foster prosocial
behaviors and healthy social relationships (Hoffman 2000),
the SPT problems of children with ADHD is concerning. In
fact, Selman and his colleagues found that lower SPT
performance during various play and group activities was
associated with poorer peer relationships, so that children
who displayed lower levels of SPT had difficulties forming
and maintaining friendships and received lower peer
nominations (Selman 2003; Selman et al. 1977). Thus, it
is plausible that the lower overall SPT skills of children
with ADHD contributes, at least in part, to their difficulties
in the social realm.
Consistent with findings from a study conducted by
Matthys et al. (1999), when asked to generate as many
ways to solve interpersonal dilemmas as they could,
children with ADHD in the present study produced
significantly fewer strategies than comparison children.
This may be a manifestation of their impulsivity and
broader executive functioning deficits, which might be
reflected in INS performance as difficulties with planning
and organizing a verbal response, keeping the strategies
provided in mind, or wanting to get the task completed as
quickly as possible. In addition, it is also possible that
children with ADHD have a smaller repertoire of solutions
to social dilemmas because their difficulties with social
skills and peer relationships (e.g. Greene et al. 1996; Hoza
et al. 2005) afford them fewer opportunities to practice
collaborative problem solving in social interactions.
Selman (2003) referred to the interpersonal orientation
aspect of the INS as a biographical lens through which
individual differences in childrens preference for giving
precedence to either the needs of the self, the other, or
effectively balancing the needs of both may be detected.
When providing alternative strategies, children with ADHD
in the current study were less likely to generate collabora-
tive and self-transforming strategies than comparison
children. Assuming that children identify with the protag-
onist in the dilemmas, this would suggest that children with
ADHD are less likely to give up some of their needs in
interpersonal situations (e.g. waiting to go second when
taking turns). Using collaborative strategies by effectively
integrating perspectives and occasionally giving up some of
ones own needs in an effort to resolve social conflicts is an
important social skill because it is related to the develop-
ment of closeness in relationships and to prosocial
behaviors (Menna and Cohen 1997); presumably closer
bonds develop between children when they feel that the
other understands their needs, beliefs and feelings, and
considers these in their interactions. The tendency for
children with ADHD to put their needs first and be less
J Abnorm Child Psychol (2009) 37:107118 115 115
cooperative may manifest in their social environment as
bossiness (Pelham and Bender 1982) and an inability to
compromise and cooperate (Cunningham and Siegel 1987).
The current study investigated the potential influence of
language proficiency, IQ, CP and ADHD diagnosis because
they are associated with SPT skills. Overall, language
ability and IQ were significant predictors of SPT, CP did
not explain variance after language and IQ were accounted
for, but ADHD diagnosis explained an additional 8% of the
variance in SPT. As predicted, our results confirm that
language abilities and IQ play an important role in SPT. CP
did not explain additional variance in SPT once language
and IQ were accounted for, likely because a significant
proportion of children with CP and ADHD have co-
occurring language impairment (Cohen et al. 1998) and
because language and CP were correlated in this study.
ADHD status, however, explained unique variance in SPT
over language. Cohen et al. (1998), who used the INS to
investigate SPT in children with language impairments,
many of whom had comorbid ADHD or ODD diagnoses,
reported that these children were impaired in SPT relative
to children with normally developing language skills. The
current study extends the Cohen et al. (1998) findings by
showing that ADHD symptomatology combines with
language difficulties to compromise the SPT skills of
children with ADHD. These results also corroborate
previous research suggesting that SPT is related to language
and intelligence and highlight the importance of assessing
these variables when examining SPT in children with
ADHD.
In the present study, girls had more developed overall
SPT skills than boys as measured by the Total INS (e.g.
Yeates et al. 1991). Earlier development of SPT in girls has
been linked to mothers and older siblings engaging in more
supportive and emotion talk with girls than boys (e.g.
Cervantes and Callanan 1998). These differences in early
interactions are believed to enhance the SPT skills of girls
from an early age (Charman et al. 2002) and are likely
reinforced in later gender-specific peer environments.
Limitations and Implications for Future Research
This study has a few limitations. First, recent research
suggests that the combined and predominantly inattentive
subtypes of ADHD may be different disorders altogether
(Milich et al. 2001). Because only two children (4%) in the
current sample met criteria for ADHD Inattentive Type
(94% were ADHD Combined and 2% were Hyperactive
Impulsive), subtype differences could not be examined.
Second, although questionnaire methods of assessing
empathy provide information about empathy as a trait, they
are also heavily influenced by childrens tendency to
present themselves favorably. Future researchers should
consider including a social desirability scale along with
self-report measures of empathy. Third, in the absence of
teacher ratings of CP, we needed to rely on parent reports,
raising the possibility that shared method variance may
have confounded the results. Future studies should examine
this further.
Implications for Clinical Practice
The findings from the present study show that deficits in
empathy are associated with oppositional and conduct
problems rather than ADHD. Consequently, clinicians
may find it helpful to assess empathy in children with
ADHD who have co-occurring oppositional and conduct
problems and to select behavioral intervention programs
that include the fostering of empathy and SPT skills
(Antshel and Remer 2003; Webster-Stratton and Reid
2003). Deficits in SPT, on the other hand, are associated
with language ability, intelligence and ADHD symptoms. It
may therefore be beneficial to explicitly teach SPT to
children with ADHD in the context of social skills training
interventions. Grizenko et al. (2000), for example, found
that 811 year old children with disruptive and impulsive
behaviors who received additional training in SPT showed
more short- and long-term improvements in behavior than
children in a traditional social skills training program. In
summary, assessing the social-cognitive skills of children
with ADHD can be an important adjunct to tradition
behavioral assessment because it provides rich information
for case formulation and can drive treatment delivery.
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