Do the Traits of Inattention and Hyperactivity Impact on Facial Affect Recognition: A Comparison Between Children with ADHD and Neurotypical Controls.

Do the Traits of Inattention and Hyperactivity Impact on Facial Affect Recognition: A Comparison Between Children with ADHD and Neurotypical Controls.

Project report submitted in partial fulfillment of the requirements of the BSc (Hons) Psychology, University of Hertfordshire

 Word Count: 6907

Abstract

Research has consistently found that children with ADHD show deficits in many areas of social functioning, including; theory of mind, language, non-verbal communication and the recognition of facial emotion. Social deficits are argued to be one of the most disabling aspects of the disorder however are not listed in the diagnostic criterion as specified by the DSM-5. At present children below the age of six get little help and rarely get a diagnosis of ADHD. Research in this area is important as social deficits that present from an early age have a large impact on social and emotional development across the lifespan. Social dysfunction is known to cause peer rejection leading to social isolation and low self-esteem. The present study compared 14 children with a clinical diagnosis of ADHD with 19 controls, matched in age and verbal ability, using the Emotion Evaluation Test (EET) from The Awareness of Social Inference Test (TASIT). It was found that children with ADHD are worse than typically developing controls in their ability to recognise and identify facial emotions. Moreover age, IQ, as well as whether a child was taking stimulant medication at the time of testing had no impact on their ability to correctly identify emotions. The trait of hyperactivity was found to have an adverse impact on the recognition of negative emotions in both children with ADHD and controls.

Keywords:  ADHD, Inattention, Hyperactivity, Social Deficits, Affect Recognition.

Do the Traits of Inattention and Hyperactivity/Impulsivity Impact on Facial Affect Recognition: A Comparison Between Children with ADHD and Neurotypical Controls.

Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by extreme, developmentally inappropriate levels of inattention, impulsivity and/or hyperactivity (American Psychiatric Association [APA], 2013). These symptoms are chronic, severe in nature and impede children’s daily functioning; impacting greatly on their home and academic life (APA, 2013). While the Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition (DSM-5)  refers to a triad of impairments; inattention, impulsivity and hyperactivity, research over the past twenty years has consistently found that children diagnosed with ADHD often suffer from additional social cognitive impairments not often accounted for (Nijmeijer, Minderaa, Buitelaar, Mulligan, Hartman & Hoekstra, 2008).

Impairments in social cognitive functioning result in impaired social interaction with peers (Hoza, 2006, Carlson et al., 1987), teachers (Greene, Beszterczey, Katzenstein, Park & Goring, 2002) and family members (Mikami & Pfiffner, 2008), often leading to academic underachievement (Fergusson & Horwood, 1995; Barry, Lyman, & Klinger, 2002) and low self-esteem (Harpin, Mazzone, Raynaud, Kahle, & Hodgkins, 2013). Deficits in social functioning are perhaps one of the most disabling elements of the disorder (Friedman et al, 2003; Ludlow, Chadwick, Morey, Edwards, & Gutierrez, N.D.) however are largely ignored by clinicians, resulting in children receiving minimal support in this central domain (Boo & Prins, 2007).

Well developed social cognitive skills are imperative for successful social-emotional development and needed for a healthy transition into adulthood (Parker & Asher, 1987). Though it is generally accepted that children and adolescents with ADHD are likely to present with significant deficits in social functioning when compared to their neurotypical peers (Nijmeijer et al. 2008; Hoza, 2006),  it is still debated whether these deficits are inherent to ADHD (Nijmeijer et al. 2008; Fonseca, 2009, Ludlow et al., 2014, Ludlow et al. N.D.), or whether they are largely a result of the disabling levels of inattention and hyperactivity that are symptomatic of the disorder (Sinzig, Morsch, & Lehmkuhl, 2008; Carpenter Rich, Loo, Yang, Dang & Smalley, 2010).  To explore this argument in more depth, it is first necessary to examine the core symptoms of ADHD, explaining how they manifest themselves in children’s social behaviour, while simultaneously discussing how these core symptoms may be accountable for the recurrent social deficits often reported.  

Although the primary symptoms of ADHD (inattention, impulsivity and hyperactivity) do not reflect problems in interpersonal functioning, many children diagnosed with the disorder experience distorted interpersonal relations and heightened levels of social rejection (Landau & Moore, 1991). This is often attributed to how these primary cognitive symptoms of ADHD manifest themselves in children’s social behaviour (Nijmeiger et al., 2008; Friedman et al., 2003, & Barkley, 2003). Reports from parents, teachers and peers often depict children with ADHD as intrusive, disruptive, unpredictable and more often than not, aggressive (Landau & Moore, 1991). It has been found that typical children often reject children with ADHD quickly, forming negative opinions from very few social exchanges, and often reacting to affected children with criticism, rejection and social withdrawal (Pelham & Bender, 1982). Social problems are reported in 52% to 82% of children diagnosed with ADHD and are documented in children as young as four years old (DuPaul, McGoey, Eckert, & Vanbrakle, 2001).

Barkley (1997) suggests that there are two prominent behavioural elements found in children with ADHD that are responsible for the high rates of social rejection they receive; the first being the perceived negative and aggressive nature of their social interactions with others. Children with ADHD often demonstrate hostile and controlling behaviour, sometimes resulting in an atypical amount of physical and verbal aggression directed towards their peers (Cunningham & Sigel, 1987; Erhardt & Hinshaw, 1994; Pelham & Bender, 1982, & Grenell et al., 1987). Secondly, children with ADHD, especially younger children, display high levels of hyperactive and impulsive behaviours. These manifest as frequent yelling, running about, excessive talking, as well of frequent interruptions of other children’s play (Nijmeiger et al., 2008). This restless, intrusive behaviour is often inappropriate to social context and resistant to correction (Barkley, 2003).

Observational studies have suggested children with ADHD are also more prone to emotional dysfunction, resulting in regular emotional outbursts and frequent “temper tantrums” (Wehmeier, Schacht, & Barkley, 2010). This inability to regulate their emotions only further exacerbates the risk of social exclusion (Erhardst & Hinshaw, 1994; & Saunders & Chambers, 1996). These types of maladaptive behaviours are strong predictors of negative peer relations, with dysfunctional peer relations being a strong indicator of social incompetence (Nejmieger et al., 2008). Much of the research described here relates to the hyperactive, impulsive and somewhat aggressive behavioural characteristics often displayed by children with ADHD, however aggression is not a diagnostic criterion of ADHD as specified in the DSM-5, nor do all children with the disorder show aggressive traits (APA, 2013; Barkley, 2003).

While all the behaviours mentioned thus far have been obvious in highlighting the antisocial behavioural characteristics of ADHD, inattention is another of the core symptoms with relatively subtle antisocial implications. Inattention can present without the additional symptoms of hyperactivity-impulsivity and is listed as a separate subtype of ADHD in the DSM-5 (APA, 2013). Children diagnosed with the inattentive subtype of the disorder are perceived as less intrusive, socially inappropriate and aggressive than their hyperactive-impulsive peers (Gaub & Carlson, 1997, Wheeler & Carlson, 2000), however are still just as likely to suffer from peer rejection (Carlson & Rapport, 1989; Carlson et al., 1987, & Hodgens, Cole & Boldizar, 2000). Inattentive children are at risk of being perceived as rude, indifferent and uncaring by others as they often struggle to listen or engage adequately in reciprocal conversation (Wheeler & Carlson, 2000). Their inability to sustain attention may lead to them missing the subtle social cues needed for effective social communication (Laudau & Milich, 1988, & Ludlow et al., 2014). It has also been found that inattentive children are more likely to be anxious, shy and more socially withdrawn in nature, thus also making them seem socially less appealing to their peers (Achenbach & Edelbrock, 1981; Nejmieger et al., 2008).

As can be seen, much research into the social dysfunction in children with ADHD focuses on the expressive deficits arising from the classic symptoms of the disorder (Barkley, 1997). Although true that many of the deficits in children’s social skills can be attributed to the core cognitive symptoms of ADHD directly (Greene et al., 1996), other implicit social cognitive deficits have been identified; such as the misinterpretation of observed social cues, difficulties understanding pragmatics, as well as deficits in theory of mind (ToM) (Uekermann et al., 2010), suggesting that there may be primary deficits of socio-emotional functioning rather than secondary deficits due to the cognitive traits of inattention and hyperactivity/impulsivity. In addition to social impairment caused by impeding levels of inattention and hyperactivity, impairment in social functioning has also been attributed to a lack of social knowledge (Grenell, Glass, & Katz, 1987), neuropsychological deficits (Barkley, 1997; Huang-Pollock, Mikami, Pfiffner, & McBurnett, 2009) as well as social information processing deficits (Crick & Dodge, 1994).

One necessary skill needed for effective social communication is the ability to understand the emotions of others, allowing for successful adaptation of interpersonal responses (Fonseca, Seguier, Santos, Poinso, & Derulle, 2009). Many studies have found that children with ADHD are worse than typically developing children at recognising facial emotions (Cadesky, Mota, & Schachar, 2000; Yuill & Lyon, 2007; Fonseca et al., 2009; Ludlow, Lawrence, Garrood, & Gutierrez, 2014). This has been argued to be due to a deficit in emotion processing rather than as a direct result of the cognitive traits of inattention or hyperactivity/impulsivity (Fonseca et al. 2009, Passarotti, et al. 2010, Brotman et al., 2010).

Children with a diagnosis of ADHD have been found to be significantly worse than typically developing controls at recognising facial emotions when asked to interpret these emotional cues from pictures (Cadesky, Mota, & Schachar, 2000). They have also been found to be worse than controls at matching emotional stories with faces displaying basic emotions (Yuill & Lyon, 2007), as well as being impaired at recognising their own emotional expressions (Fonseca, 2009). Much research on affect recognition in children with ADHD uses static images however and it is argued that social/contextual cues are necessary for effective emotion identification and recognition (Carroll & Russell, 1996; Kolb, Wilson, & Taylor, 1992).

Fonseca et al. (2009) found that children with ADHD were significantly worse than controls at both facial emotion recognition but also impaired in interpreting contextual cues to understand emotions, finding that these results were unlikely to be due to the cognitive traits of inattention and hyperactivity/impulsivity as children did not significantly differ from controls in their ability to recognise objects (Fonseca, 2009). A limitation of this study however is that while considering the social and contextual implications of emotion processing, it was still heavily reliant on the use of static images. Emotion processing in every day life is reliant on facial emotion recognition, the comprehension of social and contextual cues as well as pragmatic language proficiency. As discussed above, children with ADHD have been found to perform worse than typically developing controls across all three of these domains (Uekermann et al., 2010).

The Awareness of Social Inference Test (TASIT; Mcdonald et al., 2002) is a video-taped measure designed to assess social perception in clinical populations. The Emotion Evaluation Test is an independent part of this measure assessing the recognition of spontaneous emotional expressions as they occur over time. The actors in the TASIT are trained to convey a “real” emotion rather than to fake or imply the necessary emotion which is usually the case in conventional emotion stimuli (McDonald, 2012). The TASIT also uses video-taped interpersonal interactions unlike conventional tests of emotion that rely on static images or photographs.

In a recent study Ludlow et al. (2014) used the TASIT to examine affect recognition in children with ADHD. Their findings were consistent with the previous research, finding deficits in emotion recognition in children with ADHD regardless of their age, IQ or whether they were on medication at the time of testing (Ludlow, et al. 2014). It can be surmised thus far that many children with ADHD suffer from impaired social skills, however what still remains elusive is whether these deficits are merely a result of the antisocial behaviours symptomatic of the disorder, or whether these are deficits in social cognition are inherent to ADHD, suggestive that social functioning impairments may exist in varying degrees in all children diagnosed with the disorder. If deficits in children’s social functioning are not all attributable to the core symptoms of the disorder then medication alone will be unlikely to improve these skills (Boo & Prins, 2007).

There is a paucity of research investigating whether the cognitive traits differentially impact on one’s ability to read and understand the social cues relating to emotion. Some studies have found that the trait of inattention is associated with greater impairment in affect recognition tasks (Miller, Hanford, Fassbender, Duke, & Schweit, 2011) however a similar study investigating the social cues relating to the understanding of sarcasm found while the cognitive trait of inattention was associated with impairment in the recognition of sarcasm in typically developing children, it had no effect on children diagnosed with ADHD suggestive that there may be implicit social deficits inherent to ADHD itself (Ludlow et al., N.D.). Yuill and Lyon (2007) argue that attentional load has a greater negative impact on task performance in ADHD than typically developing children, although findings are inconsistent with other researchers finding no negative impact from the attentional demands of a task (Rapport, Friedman, Tzelepis, & Van Voorhis, 2002). As findings are inconsistent, research needs to be expanded in this area as if social difficulties are inherent to ADHD, separate to the hallmark symptoms of the disorder, then clinical interventions need to be evaluated to ensure that children are receiving adequate support after diagnosis.

The aim of this present study is to build on previous research on emotion recognition while investigating whether the traits of inattention and hyperactivity differentially impact one’s ability to recognise facial affect. By examining the traits of inattention and hyperactivity in a sample of ADHD children and neurotypical controls, the extent to which these traits impact on affect recognition can be examined. The ability to identify and differentiate between human facial emotions is a universal social cognitive skill learnt early on in life (Durand, Gallay, Seigneuric, Robichon, & Baudouin, 2007). It has been found that facial affect recognition; in typically developing individuals, is an automatic skill, made with little deliberation and not hindered by cognitive load (Tracy & Robins, 2008).

If the traits of inattention and hyperactivity are found to directly impact a child’s ability to recognise facial emotions then it would suggest that certain social deficits found in children with a diagnosis of ADHD may be due to a result of the symptoms of the condition and are not inherent to the disorder itself. However if the cognitive traits of inattention and hyperactivity do not differentially impact on affect recognition then it is suggestive that social deficits, such as impaired affect recognition, may be in fact inherent to the symptoms of ADHD itself. By submitting half of the participants to a cognitive load condition, the impact of attentional load on task performance will also be controlled for, as it has been suggested that lower performance in the task may be due to the attentional demands of the task itself (Rapport, Friedman, Tzelepis, & Van Voorhis, 2002).

It can be hypothesised therefore, that children with a diagnosis of ADHD will present with higher levels of inattention and hyperactivity, as measured on the Conners 3 (Conners, 2008) when compared to children in the control group. It is expected that children with ADHD will perform worse than controls at recognising facial emotions in both conditions (with and without cognitive load) suggesting that children with ADHD are worse at recognising facial emotions when compared to neurotypical controls, and that any results are not due to the attentional demands of the task. Finally, it is expected that individual traits will not be a significant predictor of emotion recognition, thus suggesting that children with ADHD have inherent difficulties in recognising facial emotions not attributable to individual traits of hyperactivity and inattention alone.

Method

Participants

The clinical group consisted of 14 children, 9 males and 5 females, aged between 12 and 16 years (M= 13.86, SD= 1.56) all of whom had a clinical diagnosis of ADHD.  Participants were made up of volunteers from a list of members of an ADHD/Autism charity and students from a number of mainstream schools in the South East of England. Five participants had a diagnosis of the inattentive subtype of ADHD while the remaining 9 participants had a diagnosis of the combined subtype. One child also had a confirmed clinical diagnosis of Autism Spectrum Disorder. Eight children were taking medication for their ADHD symptoms and were medicated at the time of testing; the remaining 6 were not taking medication at the time of the study. All children met the required T score of 65 or higher for hyperactivity/impulsivity and/or inattention as suggested by the guidelines (Conners, 1997). All children had a verbal IQ above 70 as confirmed by the researcher using the British Picture Vocabulary Scale-III (BPVS-III; Dunn, Dunn, Styles & Sewell, 2009). 

The control group consisted of 19 neurotypical children, 10 males and 9 females, aged between 12 and 16 years (M=13.74, SD=1.52). Participants in the control group were an opportunity sample of pupils, selected by the SENCO from a mainstream school in the South East of England.

Design

This study had a single factor between subjects design (Group: ADHD vs. Control) X (Condition: ADHD with cognitive load vs. ADHD without cognitive load vs. Control with cognitive load vs. Control without cognitive load).

Materials/Apparatus

The Conners 3 Parent Rating Scale - Revised (S) was used to measure a child’s traits of inattention and hyperactivity as reported by their parent-carer. The short version was used consisting of 27 statements assessing their behaviour over the past month. The short version provides evaluation of the key indexes of oppositional behaviours, cognitive problems and inattention, and hyperactivity. The scale consists of statements such as “inattentive, easily distracted” and “fidgets with hands, squirms in seat”. Parent-carers were asked to rate each statement on a Likert scale 0 being, not true at all (never, seldom) and 3 being, very much true (very often, very frequently).

The Conners Self Report Rating Scale (S) was used to measure a child’s traits of inattention and hyperactivity as described by them. The short version was used consisting of 39 statements assessing their behaviour over the past month. The short version provides evaluation of the key indexes of inattention, hyperactivity, impulsivity, learning problems, executive functioning, aggression and family relations, making it an ideal measure when time is limited. The scale consists of statements such as “I blurt out the first thing I think of” and “It’s hard for me to pay attention to details”. Children were asked to each statement on a Likert scale 0 being, not true at all (never, seldom) and 3 being, very much true (very often, very frequently).

The British Picture Vocabulary Scale III (BPVS III) was used to assess all children’s receptive vocabulary to ensure that the results gained from the study were not due to a child’s lack of verbal understanding of the task.

The Awareness of Social Inference Test (TASIT)/Emotion Evaluation Test (EET). The Awareness of Social Inference Test (TASIT) is made up of vignettes of everyday social interactions. Only the Emotion Evaluation Test (EET) part of the TASIT was used for this study to assesses children’s recognition of spontaneous emotional expression. The EET comprises of 28 vignettes of videotaped actors interacting in everyday situations and portraying one of seven emotions; happiness, sadness, neutral, anger, surprise, anxiety and revulsion. The TASIT randomised the order in which it played the video clips.

Participants took part in one of two conditions. TASIT with cognitive load, whereby children were shown a short 6 character code before the video clip was played which they were asked to memorise and recall after the clip had ended as well as selecting the correct emotion portrayed in the clip. There was also the TASIT with no cognitive load whereby participants were just required to watch the clips selecting the correct emotion portrayed in the clip after it had ended. Participants were counterbalanced in which condition they sat to ensure there was an equal amount of participants in each condition from each group (ADHD vs. Control).  

Procedure

Full ethical approval was obtained by the ethics committee of the University of Hertfordshire (please see Appendix A) and the procedures outlined by the British Psychological Society were followed (British Psychological Society, 2014). All participants and parent-carers were given an information sheet prior to the study explaining the aims and procedures in full (see Appendix B & C). The aims and procedures of the study were also explained again verbally on the day of testing by the experimenter. All participants were made aware that they could withdraw from the study at any time.

After obtaining consent from a parent-carer or guardian, each participant was asked for verbal and written consent (see Appendix D). All participants were tested individually. The participants from the control group were tested in a classroom at the school they attended. The participants from the clinical group were tested in a private study room at the public library closest to their home address.

Once consent was granted by all parties and participants were fully briefed on the aims and procedures of the testing, participants were given the Conners 3 Self-Report Scale to complete to measure the child’s self-perceived levels of inattention and hyperactivity. Parent-carers of children in the clinical group were also asked to complete the Conners 3 Parent Rating Scale at the same time to confirm traits of inattention and hyperactivity significantly correlated with a positive ADHD diagnosis. It was made clear that if any of the statements were not fully understood they could ask the experimenter to explain further.

Once the Conners 3 was completed children were asked to complete the British Picture Vocabulary Scale-III (BPVS-III, 2009) a standardised test of receptive vocabulary. Children were told that the task was designed to get difficult before they started and reassured that they should not be upset if they felt they did not know the answers to a set. It was made clear that once a set had begun the test had to continue to the end of the set. The experimenter reassured children they did well after test completion.

Finally, emotion recognition was measured using the EET of the TASIT. Children sat alone with headphones on so they were exposed to minimal external distractions. The experimenter explained the process to each child before they undertook the test. Children from each group (ADHD vs. Control) were counter balanced for which condition they sat, with cognitive load or without cognitive load. If children demonstrated signs of boredom the experimenter asked if they were ok, reassured with a smile or made a statement such as “Not much longer now” to reassure them.

At the end of testing all children were thanked and debriefed. They were reminded that they could withdraw from the study at any point should they no longer wish to be included. They were also made aware that the experimenter could be contacted for any further questions they may have at a later date.

 Results

Matching criteria

Analysis of variance was used to confirm that the groups were matched in verbal ability using the standardised scores of the BPVS-III. Results revealed no significant differences between the children with ADHD (M=98.00, SD=19.94) and the control group (M=102.21, SD=13.82), F(1,32)=0.52, p=.48. A similar analysis on chronological age also revealed no significant differences between ADHD children (M=13.86, SD=1.56) and controls (M=13.74, SD=1.52), F(1, 32)=0.05, p=.83.

ADHD Participants – Analysis of the Conners Parent Rating Scale.

The results of the Conners Parent Rating Scale (CPRS) were converted into standardised T-scores so comparisons between typical and atypical behaviours could be made. A repeated measures analysis of variance was used to test for differences between children diagnosed with the inattentive subtype of ADHD and children diagnosed with the combined subtype of the disorder. Using the indexes of the CPRS as a within participants factor (CPRS: Oppositional vs. Cognitive Problems/Inattention vs. Hyperactivity vs. ADHD Index) revealed the expected main effect of diagnosis, F(1,12)=5.18, p=.04, ŋ²=.30, showing higher CPRS scores in the combined subtype than in the inattentive. A main effect of CPRS was also present; F(3,36)=65.25, p<.01, ŋ²=.86. These effects were also qualified by a significant interaction, F(3,36)=4.39, p=.01, ŋ²=.27. Further analysis revealed significant differences between the subtypes on the individual indexes for oppositional behaviours and hyperactivity, however no significant differences in traits of inattention were found. Table 1 outlines the mean T-scores for the combined and the inattentive subtypes separately, and the differences between groups.

Table 1. Means and standard deviations of T scores from the CPRS by diagnosis

	ADHD Diagnosis
	Combined		Inattentive
	Mean	SD	Mean	SD	t(12)
Content Scales
Oppositional	10.44	4.00	3.40	4.51	-2.92
Cognitive Problems/Inattention	13.56	5.05	14.00	2.83	.18
Hyperactivity	10.67	4.82	1.20	1.79	-5.27
ADHD Index	26.00	7.28	24.20	4.44	-.50

Comparison of Traits/Symptoms Between ADHD Children and Controls

Analysis of the Conners Self Report Rating Scale (CSRRS) allowed for differences in traits/ADHD symptoms between groups (ADHD vs. Control) to be examined. A repeated measures analysis of variance using the scales of the CSRRS as a within participants factor (CSRRS: Inattention vs. Hyperactivity vs. Learning Problems vs. Aggression vs. Family Relations) revealed a significant effect of Group, F(1,31)=9.84, p<.01, ŋ²=.24, children in the ADHD  group, as expected received higher CSRRS ratings for ADHD symptoms/traits than children in the control group. There was also a main effect for CSRRS, F(4,124)=3.59, p=.01, ŋ²=.10. This was qualified by a significant interaction effect, F(4,124)=4.95, p=<.01, ŋ²=.30. Further analysis revealed significant differences between groups in symptoms of inattention and hyperactivity, however no significant differences were found between ADHD children and controls in terms of learning disability, aggression and family relations. Table 2 shows the means and standard deviations between groups in ADHD symptoms as well as the differences between groups.

Table 2. Means and standard deviations of ADHD symptoms between groups

	ADHD		Controls
	Mean	SD	Mean	SD	t(31)
Inattention	59.43	6.28	45.37	5.49	-6.84
Hyperactivity	51.29	6.44	44.68	4.77	-3.39
Learning Problems	50.50	9.26	46.42	8.04	-1.35
Aggression	51.43	8.56	50.42	11.99	-.27
Family Relations	47.79	7.76	46.11	6.82	-.66

The Emotion Evaluation Test

Analysis revealed no significant differences between the participants diagnosed with the combined and inattentive subtypes of ADHD, t(12)=1.28, p=.23, therefore they were collapsed for the remainder of the analysis. The scores of the individual emotions from the EET were combined into two indexes, positive emotions; averaging the scores of happiness and surprise and negative emotions, averaging the scores of sadness, anger, anxiety and revulsion.

A repeated measures analysis of variance including these indexes as a within-participants factor to the main design (Valence: Positive vs. Negative) revealed a significant effect of Valence, F(1, 31)=220.81, p= <.01, ŋ²=.87, showing that positive emotions were better recognised overall when compared to negative emotions regardless of group. A significant effect of Group was also present; F(1, 31)=7.07, p=.01, ŋ²=.19, indicating that children in the ADHD condition were less accurate at identifying emotions when compared to the children in the control group. The Valance x Group interaction was also significant F(1, 31)=5.26, p=.03, ŋ²=.15, with further analysis indicating that children with ADHD are worse than controls at recognising negative emotions (Table 3).

Table 3. Means and Standard deviations for total scores from the EET

		ADHD		Control
		Mean	SD	Mean	SD	t(31)
Happiness Surprise Sadness Anger Anxiety Revulsion Positive Index Negative Index		2.79	.89	3.21	.79	1.45
		2.57	1.40	3.16	.90	1.47
		2.64	.74	3.00	.67	1.45
		2.43	1.02	3.05	.78	2.00
		2.43	1.50	2.74	.81	.76
		2.50	1.51	3.53	.70	2.62
		5.36	1.91	6.37	1.21	1.86
		9.71	2.91	12.32	1.53	2.50

To confirm that verbal IQ and chronological age had no effect on the scores of the EET, the analysis was repeated including verbal ability and age as covariates. Results revealed that verbal IQ, age and gender were not significant predictors of EET scores. Moreover, medication also had no significant effect on the scores of the EET, t(12)=0.53, p=.61.

To enable analysis of each emotion separately for each group a repeated measures analysis of variance was used, including a within participants factor (Emotion: Happiness vs. Surprise vs. Sadness vs. Anger vs. Anxiety vs. Revulsion) in the main design. Results showed no significant main effect for Emotion; F(5,155)=1.38, p=.24, ŋ²=.04, suggestive that no individual emotion was recognised better than others. The main effect for group was significant, F(1, 31)=5.45, p=.03, ŋ²=.15, again indicating children in the ADHD group were less accurate at recognising emotions when compared to controls regardless of individual emotion. There was no significant interaction effect, F(5,155)=0.90, p=.48, ŋ²=01.Therefore children were no better at identifying any individual emotion in particular regardless of which group they were from.

ADHD Content Scales on Emotion Recognition

Regression analysis was used to investigate the effects of each of the content scales of the Conners Self Report Rating Scale; (inattention, hyperactivity, learning problems, aggression and family relations), on the emotion scales of the EET. Children in the ADHD group were analysed separately from children in the control group using separate indexes, one for positive and one for negative emotions from the EET. Results revealed that for the index of positive emotions, none of the predictors reached significance in the control group, R=.51, F(5,18)=2.67, p=.07. There were also no significant predictors of the model found for the ADHD group for the index of positive emotions, R=.58, F(5,13)=2.20, p=.15. For the index of negative emotions, hyperactivity and aggression were significant predictors of the model in the control group, R=.55, F(5,18)=3.18, p=.04, and learning problems and hyperactivity were significant predicators of the model in the ADHD group, R=.87, F(5,13)=10.47, p<.001. Table 4 outlines the correlations of the positive and negative indexes on the individual emotions of the EET.

Table 4. Pearson correlations and Standard regression coefficient of Conners Content Scales on Positive (PI) and Negative (NI) indexes

	1	2	3	4	5	PI	NI
ADHD Group
Inattention (1)	-					-.25	-.42
Hyperactivity (2)	.31	-				-.39	-.60*
Learning Problems (3)	.40*	.12	-			-.67*	-.75*
Aggression (4)	.30	.35	-.02	-		-.23	-.02
Family Relations (5)	.40	.29	-.04	.42	-	-.10	-.16
Control Group
Inattention (1)	-					-.08	-.29
Hyperactivity (2)	.49*	-				-.11	-.48*
Learning Problems (3)	-.16	.25	-			.32	.12
Aggression (4)	.20	.60*	.53*	-		.32	-.44*
Family Relations (5)	.44*	.51*	.61*	.52*	-	.25	.09

* p=0.05.

Cognitive Load

Finally, repeated measures analysis of variance was used to analyse the effect of cognitive load on emotion recognition between the different EET conditions, using a within participants factor (EET scores: Positive vs. Negative) in the main design (Table 5). Analysis revealed a significant main effect for EET, F(1,29)=219.82, p<.01, ŋ²=.88, indicating there were significant differences between scores regardless of EET condition, again confirming that positive emotions are better recognised than negative emotions. There was also a significant main effect for condition, F(3,29)=5.26, p=.01, ŋ²=.35, indicating that condition had a significant effect on EET scores within individual conditions.  The EET x Condition interaction was not significant however, F(3,29)=2.35, p=.09, ŋ²=.20, suggestive that condition had no effect on EET score. Further analysis revealed that though controls were better at recognising emotions in general when compared to children in the ADHD group, regardless of condition, cognitive load had no significant effect on performance in the Emotion Evaluation Test.

No significant differences were found between ADHD children in the cognitive load condition and condition without load, nor were any significant differences found between children in the control group, with or without cognitive load. Controls outperformed children in the ADHD group in the condition without cognitive load for both positive, t(14)=2.50, p=.03, and negative emotions, t(7.33)=2.96, p=.02. No significant differences were found in emotion recognition between controls and children with ADHD in the cognitive load condition however for either positive t(14.34)=-.16, p=.87, or negative emotions, t(8.48)=.53, p=.61. Table 5 outlines the means and standard deviations of the scores of the EET in the separate conditions.

Table 5. The means and standard deviations of EET scores by condition.

	ADHD No Load		ADHD Load		Control No Load		Control Load
	Mean	SD	Mean	SD	Mean	SD	Mean	SD
Positive	4.43	2.30	6.29	0.76	6.56	1.01	6.20	1.40
Negative	8.14	3.93	11.29	2.81	12.78	1.48	11.90	1.52

Discussion

The current study investigated the ability of children diagnosed with ADHD to recognise cues of emotions using naturalistic vignettes, representative of the complex and dynamic ways in which emotions are displayed in day to day life. It was found that children with ADHD are worse at identifying emotions in general when compared to neurotypical controls. Positive emotions were better recognised than negative emotions by all children. The trait of hyperactivity was found to have a significant impact on the recognition of negative emotions in both children with ADHD and typically developing controls. Cognitive load demands had no significant effect on emotion recognition in children with ADHD or controls, suggestive that performance was not due to the attentional demands of the task. It was confirmed that results were not affected by differences in age, verbal ability, or gender. Stimulant medication also had no significant effect on emotion recognition in children with ADHD.

The clinical sample in the present study did not exclude on the basis of diagnosis, comorbid psychiatric disorders, or whether a child was taking stimulant medication at the time of testing. As a large majority of children diagnosed with ADHD will also present with comorbid psychopathologies; the most common being ASD, oppositional defiance and conduct disorder (Pliszka, 1998), the present sample is representative of the clinical population. Most importantly, it was found medication had no effect on children’s ability to recognise emotions. Therefore, it is suggestive that though medicated, children with ADHD are still unable to notice the subtle social cues of emotion and are unable to decipher emotions as well as typically developing controls, leaving them at a disadvantage when compared to their typically developing peers.

At present, stimulant medication is the most popular method of treatment for the symptoms of ADHD, however this study highlights that while medication may treat the adverse symptoms of inattention and hyperactivity prevalent to the disorder, it suggests that social deficits, such as impaired affect recognition, are not necessarily due to the symptoms of inattention and hyperactivity alone. Deficits in social skills are observed in pre-school aged children at risk of ADHD (Nijmeijer et al. 2008, DuPaul, McGoey, Eckert, & Vanbrakle, 2001), as well as being consistently reported by parent-carers of children with ADHD from a young age (Hoza, 2006). This is important to note as ADHD is rarely diagnosed in children less than six years of age, meaning children get little support pre-diagnosis, (APA, 2013). This study supports the need of further research into the social functioning in children with ADHD, addressing the age of onset as well as investigating viable treatment plans with inclusive support for development of social skills, including emotion recognition.  

Children in the ADHD group had either a diagnosis of the inattentive subtype, or the combined subtype of the disorder. When examining the results of the Conners parent rating scale, it was found that children diagnosed with the combined subtype showed significantly more oppositional and hyperactive traits than children diagnosed with the inattentive subtype of ADHD. These behaviours have been linked to deficits in social functioning and peer relations (Nijmeijer et al. 2008, Barkley, 2003). No significant differences in traits of inattention were found, as reported by the CPRS however. While no differences were found in emotion recognition between the two subtypes, it is important to note that both subtypes share the common trait of inattention. It was revealed that the trait/symptom of hyperactivity had a negative impact on the recognition of negative emotions for both the children with ADHD and typically developing controls. As there were no children in the sample diagnosed with the hyperactive-impulsive subtype of the disorder, no conclusions could be drawn regarding the traits of hyperactivity-impulsivity and their impact on recognition of affect independent of additional attention deficits.  The traits of hyperactivity-impulsivity have been shown to have a detrimental effect on social cognition in children with ADHD (Barkley, 1997, Barkley, 2003), therefore it would be useful to be able to compare all three subtypes of the disorder to investigate how these traits individually impact on affect recognition. As no significant difference in affect recognition was found between children diagnosed with the inattentive or combined subtype of the disorder in the present study, the subtypes were collapsed into one group for the remainder of the analysis.

Evaluation of the Conners Self Report Rating Scale revealed no significant differences between children diagnosed with ADHD and neurotypical controls in terms of their levels of aggression, family relations, or learning problems. As expected, ADHD children presented with significantly higher levels of inattention and hyperactivity than the children in the control group. Findings would suggest that the traits of inattention and hyperactivity are not directly responsible for social deficits relatable to family relations, learning problems and aggression however, as the clinical group did not significantly differ from controls in these areas (Nijmeijer et al. 2008, Hoza, 2006, Barkley, 2003). It is important to note that these traits were measured via the Conners self report rating scale however, and research has suggested that children with ADHD are often unaware of the social deficits they present with, often rating themselves much higher than perceived by others (Nijmeijer et al. 2008, Hoza, 2006).

The findings of the present study found that children with ADHD were worse than controls at identifying emotions when compared to neurotypical controls. While no evidence was found to suggest that any emotion was recognised better over any other, it was found that positive emotions were better recognised than negative emotions in general. This was the case for children with ADHD as well as typically developing controls. This is consistent with previous research in the area by Ludlow et al., (2014). Analysis suggested that there was a significant relationship between the trait of hyperactivity and the ability to recognise negative emotions for both children with ADHD and neurotypical controls. These findings are significant as it includes measures of these traits in the general population. The fact that hyperactivity in controls correlated with an impaired ability to recognise negative emotions, is suggestive that the trait of hyperactivity may be responsible for some aspects of impaired social cognitive function. Elevated levels of hyperactivity in children with ADHD would therefore cause significant impairments. Aggression was also found to be a significant predictor for impaired recognition of negative emotions in the control group as was learning problems in the ADHD group. No individual traits were significant predictors for the ability to recognise positive emotions. More importantly, inattention was not found to have any significant relationship to children’s ability to identify emotions. This is important as all children in the clinical group had high traits if inattention as reported by themselves and by parent-carers.

Cognitive load had no significant impact on task performance, therefore it can be suggested that deficits found in emotion recognition are not relatable to the attentional load needed for the task. Though no significant differences in performance were found between groups (ADHD vs. Control) under cognitive load, children with ADHD under cognitive load were no longer significantly different from controls under the cognitive load condition, suggestive that children with ADHD performed marginally better under cognitive load. Due to the small sample in the present study, it would be useful to run the study again on a larger scale to see if this improvement under cognitive load could be replicated.  

The clinical sample used for the study was small, n(14), therefore to validate any findings, research would need to be carried out on a much larger sample. The study also did not include any children in the clinical sample with a diagnosis of the hyperactive-impulsive subtype of ADHD. As findings have shown a significant relation between the trait of hyperactivity and accuracy of emotion recognition it would be useful to test again including all three subtypes of the disorder for comparison. To evaluate the traits/symptoms of children in more detail it would also be useful to test again, using the full Conners rating scales, collating data from parents, children and teachers, for both children with ADHD and controls to allow for a more reliable measure of the individual traits.

To surmise, the findings of this study confirm that children with ADHD are worse than typically developing controls at recognising facial emotions consistent with previous research (Fonseca et al, 2009, Ludlow et al. 2014). These deficits exist independent of verbal IQ, age or gender (Ludlow et al. 2014). Again consistent with findings by Ludlow et al. (2014) it was found that stimulant medication had no impact on a child’s ability to recognise and identify emotion, suggestive that deficits in emotion recognition may not be directly attributable to the excessive traits of inattention and hyperactivity alone. Results of the Conners self report rating scale revealed that although children with ADHD differed from controls in their traits of inattention and hyperactivity, they did not differ from controls in self reported levels of learning problems, aggression or family relations. It was found that the trait of hyperactivity had a significant relationship with the recognition of negative emotions in both children with ADHD and in typically developing children, with children with high levels of hyperactivity being less accurate at the identification of negative emotions. Cognitive load had no significant impact on emotion recognition for children with ADHD or controls suggestive that impairments in emotion recognition were not due to the attentional demands of the task.

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