Turkish Journal of Psychiatry 2013

Alterations in Social Reciprocity in Attention-Deficit Hyperactivity

Disorder
2
Aye Burcu AYAZ1, Muhammed AYAZ2, Yank YAZGAN3

SUMMARY
Objective: Social interactions in children with attention deficit-hyperactivity disorder (ADHD) are inappropriate and such social problems may
originate from a failure to attend to the appropriate cues of affect. The present study aimed to determine the factors predictive of social reciprocity
in ADHD and their relationship to sociodemographics.
Materials and Methods: Participants were required to interpret emotional cues depicted in pictures of facial expressions with a test that was adopted from the Reading Mind in the Eyes Test (RMET). Diagnoses were established based on the Kiddie Schedule for Affective Disorders and
Schizophrenia (K-SADS-PL). Moreover, a detailed sociodemographic form, the Child Behavior Checklist (CBCL), and the Social Reciprocity Scale
(SRS) were used for assessment.
Results: This study included 133 children; 64 in the ADHD group and 69 in the control group. There wasnt a significant difference in mean age
between the ADHD group (13.22 1.28 years) and control group (12.97 1.27 years). In all, 50% of the ADHD group and 49.3% of the control
group were male. The mean RMET score was significantly lower in the ADHD group than in the control group (ADHD group: 20.52 3.95;
control group: 23.70 3.55) and the mean SRS score was significantly higher in the ADHD group than in the control group (ADHD group: 65.84
18.83; control group: 36.04 16.32). In the ADHD group attention problems and lower level of ability to interpret emotional facial expressions
were predictive of impaired social reciprocity.
Conclusion: The findings show that both the ability to decode facial expressions and social reciprocity were impaired in the ADHD group. These
findings highlight the difficulty children with ADHD have with social functioning and interpretation of emotions based on facial expressions.
Keywords: Attention deficit-hyperactivity disorder, child, social problems, comorbidity

INTRODUCTION
Attention deficit-hyperactivity disorder (ADHD) is characterized by carelessness, hyperactivity, and impulsivity, and it is
thought that the disorder affects 3%-5% of school-age children
worldwide (Polanczk et al. 2007). ADHD causes loss of cognitive, academic, family, and professional functioning (Barkley
2003). Another area impaired by ADHD is social functioning.
Impaired social functionality primarily emerges in the form of
problematic and/or lack of peer relationships, and relationships
with adults/parents that are prone to be conflictual. In addition, impaired social functioning is associated with unfavorable
short- and long-term ADHD prognoses (Greene et al. 1996).

Social functioning is based on cognitive and social skills, and is

influenced by individual and environmental factors (Wyman
et al. 2000). Meeting social needs and reaching social targets
in a given environment, and in defined social interactions
requires the use of many resources. Basic emotional/perceptual, cognitive, and emotional structures are necessary for
the development of social skills. Socialization and the ability
to understand facial expressions, emotions, and what others
are thinking are among the high-level social skills that contribute to social competence, and are required to exhibit the
appropriate behavior required by a social context (Guralnick
2005). Social reciprocity is a component of social functioning and is defined as, initiating and maintaining reciprocal

Received: 15.09.2011 - Accepted: 28.06.2012

1,2
MD, Sakarya University Training and Research Hospital, Child and Adolescent Psychiatry, Sakarya. 3Prof., Marmara University Department of Child and Adolescent Psychiatry, Istanbul,
Turkey.

E-mail: drburcu2000@yahoo.com

relationships, and reacting in way appropriate to the social

context.
Some problematic social behaviors in children could be a direct outcome of the symptoms of ADHD. Some of the DSMIV ADHD criteria, such as, interrupting others while they
are talking and interfering in their affairs, are indicative of
inadequate social behavior. Children diagnosed with ADHD
usually have problems understanding social cues, misinterpret
social situations, and behave inappropriately for a given social
context. Such children are usually considered to be insensitive
to the needs of other people, and patronizing and disturbing (Weiss 2002). In general, the coexistence of hyperactivity,
impulsivity, and attention deficit affects the fine-tuning of social behaviors; however, not all children with ADHD exhibit
problematic social behavior. In addition, DSM-IV ADHD
diagnostic criteria do not define all of the inadequate social
behaviors observed in children with ADHD. It is thought
that the social problems associated with ADHD may stem
from inability to correctly interpret facial expressions. Social
interactions require the skills to understand and interpret the
emotional states of people based on their facial expressions
(Adolphs 2003). Studies on the theory of mind, and the ability to understand others emotions reported that children with
ADHD have difficulty understanding the emotions of others
based on facial expressions (Yuill and Lyon 2007).
Other important indicators of poor social functioning are conduct disorder (CD) and oppositional defiant disorder (ODD),
both of which are frequently comorbid with ADHD in clinical
and community samples (Spencer 2006). It was reported that
when ADHD in children is not treated CD, which is associated with criminal behavior, can develop during adolescence
(Biederman and Faraone 2005). In cases of ADHD and comorbid ODD or CD, social deficit is more severe (Bagwell et
al. 2001). More children diagnosed with ODD and/or CD comorbid with ADHD experience conflicts with parents, teachers and their friends than those diagnosed only with ADHD
(Edwards et al. 2001; Gresham et al. 1998).
Some studies that investigated impaired social functioning
in ADHD focused on comorbid diagnoses, whereas others
examined etiology; however, few studies have addressed social reciprocity and understanding emotions based on facial
expressions in ADHD. The present study aimed to determine
the factors predictive of social reciprocity in ADHD and their
relationship to sociodemographics.

MATERIALS and METHODS

Sample
The present study was performed at Marmara University,
School of Medicine, Child and Adolescent Psychiatry
Department, Outpatient Clinic. The study protocol was
approved by the Marmara University School of Medicine
Ethics Committee (MAR-Y-2008-0241). The parents of

all children and adolescents aged 12-16 years that were diagnosed as ADHD according to DSM-IV diagnostic criteria
between September 2008 and January 2009 were contacted
by phone and invited to participate in the study. The ADHD
group included children and adolescents that, along with
their parents, consented to participate in the study. Children
with mental retardation, autism spectrum disorder, and any
chronic medical disease were excluded from the study.
The control group consisted of healthy students matched
for age and sociodemographics randomly selected from the
school closest to our hospital. In order to include students
from this school permission was obtained from the stanbul
National Education Directorate. The Child Behavior
Checklist (CBCL) was administered to the parents of the students and those in which the signs of psychiatric disorders
were not detected were invited to participate in the study.
Students with mental retardation, any chronic medical disease, and any psychiatric disorder based on a semi-structured
diagnostic interview were excluded from the study.

Tools
Sociodemographic information form
Sociodemographic data for the children participating in the
study were obtained using a sociodemographic information
form developed by the investigator to collect data on developmental milestones, drug use, and family history.

Kiddie-Schedule for Affective Disorders and

Schizophrenia for School-Age Children, Present and
Lifetime Version (K-SADS-PL)
K-SADS-PL is a semi-structured interview that was developed
by Kauffman et al. (1997). It was reported to be reliable and
valid for use in Turkey by Gkler et al. (2004). K-SADS-PL
is used to determine present and life-long psychopathology
in the children and adolescents, and is administered in consideration of DSM-IV diagnostic criteria. The form includes
3 parts. The first collects data on demographic characteristics and general health status, previous psychiatric referrals
and related treatment, relationships with family and peers,
and school performance. The second part is used for screening specific psychiatric symptoms and diagnostic criteria. If
positive symptoms are noted via the screening interview, an
additional symptom list is used to further evaluate psychopathology. The presence or severity of symptoms is determined
via joint evaluation of the opinions of the child or adolescent,
parents, and clinician. K-SADS-PL can be used to evaluate affective disorders, psychotic disorders, anxiety disorders, elimination disorders, disruptive behavior disorders, substance
abuse, eating disorders, and tic disorders. The third part is a
general evaluation scale used to determine the present level of
functioning. At minimum, 1 parent that can provide information about the child participates. K-SADS-PL was used to
identify psychopathology in the participants.

Child Behavior Checklist (CBCL) (age 4-18 years)

CBCL was developed by Achenbach and Edenbrock (1983).
The 1991 version of CBCL was translated into Turkish by
Erol and Kl, and in order to ensure consistency with the
1985 Turkish form (Akakn 1985) the translations were reviewed (Erol and imek 1998). CBCL yields 2 behavioral
symptom scores, i.e. internalizing problems and externalizing problems. The internalizing score is obtained by summing the social withdrawal, somatic complaints, and anxiety/
depression subscale scores, whereas the externalizing score is
based on the sum of the delinquent behavior and aggressive
behavior subscale scores. In addition to internalizing and externalizing symptoms, the scale also assesses social problems,
thought problems, sexual problems, and attention problems.
The sum of these subscale scores yields an overall problem
score. In terms of the CBCL total score, its test-retest reliability was reported to be 0.84 and its inner consistency was
0.88 (Erol et al. 1995). Parents complete the scale using a
3-point Likert-type scale: 0 = not true (0), 1 = sometimes
or partly true, and 2 = mostly or frequently true. CBCL was
used in this study to determine the severity of emotional and
behavioral problems in the participants.

emotional states is scored as follows: <22 correct answers: low;

22-30 correct answers: moderate; >30 correct answers: high.
Based on a study on Turkish adults, the test was reported to
be reliable for use in Turkey (Yldrm et al. 2011). The reliability of the test for use with Turkish children has not been
studied. We performed a pilot study on the inner consistency
of the test with 100 children and adolescents aged 12-16
years, and Cronbachs alpha value was 0.496, which was considered indicative of moderate-level reliability. The internal
consistency of the scale was reported to be 0.60 (Voracek et al.
2006); therefore, the scale was considered suitable for use in
the present study and was used to determine the distribution
of RMET characteristics in the patients and controls.

Wechsler Intelligence Scale for Children-Revised

(WISC-R)
WISC-R was developed by Wechsler (1949) for evaluating
the intelligence capacity of children aged 6-16 years that have
an adequate level of speech and language skills. The scale
adapted for use in Turkey by Savar and ahin (1995). In
the present study WISC-R was used to determine the level of
intelligence of the patients and controls.

Social Reciprocity Scale (SRS)

Administration

SRS was developed by Constantino in 2000 and has been

shown to have high reliability and validity, and as such is
strongly correlated with the diagnosis of autism made using
the Autism Diagnostic Interview-Revised and can be used
to evaluate autism-like symptom clusters (Constantino et al.
2003; Constantino, 2000). The scale includes 39 items targeting reciprocal social behavior and communication, 6 items on
social use of language, and 20 items on autistic traits. Higher
total scores indicate greater severity of social impairment.
Although the reliability and validity of the Turkish version
have not been reported it was used in a large-scale study on
school-age children by nal et al. In the present study the
scales inner consistency was (Cronbachs alpha value) 0.86,
and following factor analysis it was decided that the scale
would be included in evaluations as a whole (single factor).
The test-retest reliability of the SRS-Turkish Version was high,
based on data obtained 6 months apart (Pearsons r = 0.53, P
< 0.001) (nal et al. 2008). SRS was used in the present study
to evaluate social functioning in the participants.

The participants and their parents were informed about the

study by the investigator, and the parents provided written
informed consent. In children with ADHD that were using
medication, the medication was discontinued for 24 h before
evaluation to ensure that evaluation was made while in a nonmedicated state. The children and adolescents in the ADHD
and control groups underwent 2 interview sessions. During
the first interview the sociodemographic information form
was completed by the clinician and the RMET was administered. In addition, all children and their parents were administered K-SADS-PL. Additionally, the mother or father of each
participant was administered the SRS and parents of those in
the ADHD group were administered the CBCL. Diagnoses
that could not be screened via K-SADS-PL were evaluated by
the investigator based on DSM-IV diagnostic criteria. After
the interview treatment arrangements were made for those in
the ADHD group. Children in the control group that were
diagnosed with an Axis I disorder based on a semi-structured
interview were referred to Marmara University, School of
Medicine, Child and Adolescent Psychiatry Outpatient
Clinic for treatment. WISC-R was administered by a consultant psychologist during the second interview session.

The Reading the Mind in the Eyes Test (RMET)

RMET is a cognitive empathy test that measures the theory of
mind skills in adults (Baron-Cohen et al. 2001). The revised test
has 36 items, and includes pictures of eyes and the part of the
face around the eyes of actors and actresses. Accompanying each
picture (item) are the names of 4 emotional states, 1 of which
is true and 3 of which are false. Participants must choose the
word corresponding to the emotional state of the person in the
picture based on visual information only. The skill of judging

Statistical analysis
Data were analyzed using SPSS v.15.0 for Windows. The
chi-square () test was used to compare numerical data,
and Students t-test was used to compare continuous variables. Analysis related to SRS and RMET was performed

using covariance analysis (ANCOVA), and hence the difference between intelligence levels measured via WISC-R were
controlled for. Some evaluations of the SRS scale were made
using logistic regression analysis. For all analyses the level of
statistical significance was set at P < 0.05.

RESULTS
In all, 133 children and adolescents (64 in the ADHD group
and 69 in the control group) were included in the study. Mean
age in the ADHD group (13.22 1.28 years) and control
group (12.97 1.27 years) was similar (t = 1.120, P = 0.265).
In total, 50% of the ADHD group (n = 32) and 49.3% of

the control group was male (n = 34) ( = 0.007, P = 0.933).

Developmental milestones in the ADHD and control groups
were as follows: first words spoken: mean age of 12.08 4.81
months and 10.39 3.02 months, respectively; first sentences
spoken: mean age of 20.56 7.74 months and 17.78 5.51
months, respectively; first walked: mean age of 12.11 3.80
months and 12.03 2.24 months, respectively; completed
toilet training: mean age of 21.03 8.24 months and 18.17
5.18 months, respectively. There were significant differences
between the 2 groups in terms of first word spoken (t = 2.440,
P = 0.016), first sentence spoken (t = 2.400, P = 0.018), and
completion of toilet training (t = 2.413, P = 0.017) (Table 1).

Table 1. Demographic characteristics and developmental milestones in the ADHD and control groups
ADHD Group
(n = 64)

Control Group
(n = 69)

Statistical analysis

n (%)

n (%)

Test statistics, P value

32 (50)
32 (50)

34 (49.3)
35 (50.7)

= 0.007, P = 0.933

Kindergarden training

37 (57.8)

39 (56.5)

= 0.020, P = 0.880

Learning to read
1st semester
2nd semester

50 (78.1)
14 (21.9)

68 (98.6)
1 (1.4)

= 13.838, P = 0.000

6 (9.4)

0 (0)

P = 0.009*

Demographic characteristics

Gender
male
female

Repetition of grade

Mean SD

Mean SD

Age (years)

13.2 1.29

12.97 1.27

t = 1.120, P = 0.265

Developmental milestones
First word (months)
First sentence (months)
Walking (months)
Toilet training (months)

12.08 4.81
20.56 7.74
12.11 3.80
21.03 8.24

10.39 3.02
17.78 5.51
12.03 2.24
18.17 5.18

t = 2.440, P = 0.016
t = 2.400, P = 0.018
t = 0.150, P = 0.881
t = 2.413, P = 0.017

*Fishers exact test

Table 2. Demographic characteristics of the parents

Mean SD
39.70 5.94
44.39 6.72
4.68 3.72
n (%)

Control Group
(n = 69)
Mean SD
40.99 5.01
43.39 7.14
2.40 5.30
n (%)

Mothers Level of Education

illiterate/primary school
secondary school
high school
university

22 (34.4)
8 (12.5)
26 (40.6)
8 (12.5)

12 (17.4)
15 (21.7)
26 (37.7)
16 (23.2)

Fathers Level of Education

illiterate/primary school
secondary school
high school
university

17 (26.6)
12 (18.8)
21 (32.8)
14 (21.9)

9 (13.0)
13 (18.8)
26 (37.7)
21 (30.4)

58 (90.6)
6 (9.4)

64 (92.8)
5 (7.2)

ADHD Group (n = 64)

Mothers age (years)
Fathers age (years)
Age difference (years)

Mother-father relationship status

Together
Divorced/separated

Statistical analysis
Test statistics, P value
t = 1.348, P = 0.182
t = 0.834, P = 0.413
t = 2.851, P = 0.008

= 7.564, P = 0.059

= 4. 248, P = 0.242

= 0.223, P = 0.661

Table 3. Comparison of CBCL, RMET, and SRS scores between the ADHD and control groups
ADHD (n = 64)
Control (n = 69)
CBCL
64.39 7.87
45.87 10.49
Overall problems
59.75 10.17
48.96 11.92
Internalizing problems
62.06 9.02
44.12 8.19
Externalizing problems
59.64 9.48
53.04 5.78
Social withdrawal
58.47

9.49
55.30 6.65
Somatic complaints
59.75

8.12
54.64 6.25
Anxiety/Depression
58.63

7.61
50.96 1.99
Delinquent Behavior
63.77

9.62
51.51 3.32
Aggressive Behavior
61.31

8.87
52.07 3.66
Social problems
60.95 8.87
52.93 4.97
Thought problems
68.36 7.73
51.78 3.59
Attention problems
20.52 3.95
23.70 3.55
Number of correct RMET answers
65.84

18.83
36.04
16.32
SRS total score
94.06

13.30
113.25
13.35
WISC-R

Statistical analysis
t = 11.445, P < 0.001
t = 5.595, P < 0.001
t = 12.022, P < 0.001
t = 4.883, P < 0.001
t = 2.241, P = 0.027
t = 4.084, P < 0.001
t = 8.082, P < 0.001
t = 9.964, P < 0.001
t = 7.958, P < 0.001
t = 6.701, P < 0.001
t = 16.045, P < 0.001
t = 4.894, P < 0.001
t = 9.770, P < 0.001
t = 8.294, P < 0.001

CBCL: Child Behavior Checklist; RMET: Reading the Mind in the Eye Test; SRC: Social Reciprocity Scale; WISC-R: Wechsler Intelligence Scale For Children-Revised.

The number of patients and controls that attended kindergarden was similar in the ADHD and control groups (respectively, 48.7% and 51.3%): however, those in the ADHD group
learned to read and write significantly later and repeated
grades more frequently than those in the control group (P <
0.05, see Table 1). The ADHD and control groups were similar with regard to their parents mean age, their level of education, and the status of their relationship (togetherness). The
difference between the ages of the mothers and fathers was
significantly lower in the control group (P < 0.05) (Table 2).
In ADHD group the time from the onset of complaints (4.91
2.06 years) to first presentation to the clinic (9.67 2.94
years) was 4.77 2.96 years. In all, 87.5% (n = 56) of the
ADHD group received drug treatment at any time following
presentation to the clinic or were currently using medications.
Among those in the ADHD group with history of drug treatment, 80.4% were using medication at the time the study
was conducted, 75% received drug treatment for 1 year,
and 82.1% benefited from such treatment. The distribution
of drug treatments was as follows: methylphenidate alone:
67.9%; risperidone alone: 1.8%; methylphenidate + risperidone: 12.5%; methylphenidate + selective serotonin reuptake
inhibitors (SSRIs): 3.6%; methylphenidate + risperidone
+ SSRIs: 3.6%; methylphenidate + other drugs: 10.7%. As
atomoxetine was not used by anyone in the ADHD group
during the study period, there are no data on treatment with
this drug.
In all, 54.7% (n = 35) of the ADHD group had 1 comorbid
diagnosis and the rates were as follows: ODD: 21.9%; CD:
7.8%; tic disorders: 17.2%; presumptive diagnosis of dyslexia: 4.7%; stuttering: 4.7%; major depressive disorder: 4.7%;
social phobia: 10.9%; specific phobia: 1.6%; general anxiety
disorder: 3.1%; panic disorder: 1.6%; encopresis: 1.6%.

WISC-R verbal, performance, and total scores were 90.08

14.80, 98.30 14.19, and 94.06 13.30, respectively, in the
ADHD group, versus 110.26 13.03, 114.81 14.79, and
113.25 13.35, respectively, in the control group. The difference between the ADHD and control groups was significant
for the verbal (t = 8.359, P < 0.001), performance (t = 6.559,
P < 0.001), and total scores (t = 8.294, P < 0.001) (Table 3).
Mean CBCL scores in the ADHD and control groups were,
respectively, as follows: total score: 64.39 7.87 and 45.87
10.49; internalizing problems subscale: 59.75 10.17 and
48.96 11.92; externalizing problems subscale: 62.06 9.024
and 4.12 8.19. The difference between the 2 groups was
significant for total (t = 11.445, P < 0.001), internalizing
problems subscale (t = 5.595, P < 0.001), and externalizing
problems subscale (t = 12.022, P < 0.001) scores (Table 3).
The mean number of RMET correct answers was 20.52
3.95 in the ADHD group and 23.70 3.55 in the control
group; the number of correct answers was significantly lower
in the ADHD group (t = 4.894, P < 0.001) (Table 3). An
SRS score 60 indicates sub-threshold clinical problems. SRS
scores were 60 in 54.7% (35) of the ADHD group and 8.7%
(6) of the control group. Mean SRS score was 65.84 18.83 in
the ADHD group and 36.04 16.32 in the control group; the
difference was significant (t = 9.770, P < 0.001) (Table 3). The
number of correct RMET answers was evaluated after controlling for WISC-R scores, which showed that the control groups
score (mean 95% CI: 23.59 2.59-24.59) was significantly
higher than the ADHD group score (mean 95% CI: 20.63
19.58-21.68) (F [df ]: 13.53 [1], P < 0.001), and the difference
between the ADHD (mean 95% CI: 63.40 58.57-68.24)
and control groups (mean 95% CI: 38.30 33.68-42.92) (F
[df ]: 45.64 [1], P < 0.001) remained significant.
CBCL scores were as follows: social withdrawal subscale:
ADHD group (mean: 59.44; 95% CI: 57.26-61.62) vs.

Table 4. Outline of the regression model, indicating the variables that affect social reciprocity in children diagnosed with ADHD

Independent Variables

Non-Standardized
Coefficients
Beta

Standardized
Coefficients

Standard
error
30.209
1.593
0.388
4.014

0.004
0.011
0.063

95% CI

VIF

0.376
0.973
0.914
0.557

(87.462)-(33.571)
(3.245)-(3.137)
(0.735)-(0.819)
(10.414)-(5.668)

0.892
0.034
0.109
0.591

1.339
1.125
1.310

Beta

Constant
Age
First word
Comorbid diagnosis

26.945
0.054
0.042
2.373

Drug use

2.819

5.567

0.050

0.615

(13.971)-(8.332)

0.506

1.112

0.059

0.135

0.041

0.665

(0.211)-(0.328)

0,435

1.036

1.065

0.477

0.223

0.030

(2.021)-(0.109)

2.231

1.146

0.243

0.679

0.000

(1.168)-(2.141)

6.818

1.137

WISC-R total score

Number of correct RMET
answers
CBCL attention problems

1.654

R = 0.715 R = 0.511

F = 8.366

P = 0.000

Durbin-Watson = 1.972

WISC-R: Wechsler Intelligence Scale for Children-Revised; RMET: Reading the Mind in the Eye Test; CBCL: Child Behavior Checklist.

control group (mean: 53.23: 95% CI: 51.15-55.31) (F [df ]:

13.79 (1), P < 0.001); somatic complaints subscale: ADHD
group (mean: 58.84; 95% CI: 56.57-61.12) vs. control group
(mean: 54.96: 95% CI: 52.79-57.13) (F [df ]: 4.95 1], P =
0.028); anxiety/depression subscale: ADHD group (mean:
59.57; 95% CI: 57.55-61.59) vs. control group (mean:
54.81; 95% CI: 52.88-56.74) (F [df ]; 9.43 [1], P = 0.003);
social problems subscale: ADHD group (mean: 60.90; 95%
CI: 59.03-62.77) vs. control group (mean: 52.46; 95% CI:
50.67-54.24) (F [df ]: 34.64 [1], P = 0.000); thought problems subscale: ADHD group (mean: 60.44; 95% CI: 58.5262.36) vs. control group (mean: 53.40; 95% CI: 51.57-55.24)
(F [df ]: 22.68 [1], P = 0.000); attention problems subscale:
ADHD group (mean 95% CI: 68.17 66.51-69.84) vs.
control group (mean 95% CI: 51.96 50.36-53.55) (F
[df ]: 160.65 [1], P = 0.000); delinquent behavior subscale:
ADHD group (mean: 58.77; 95% CI: 57.24-60.30) vs.
control group (mean: 50.82; 95% CI: 49.36-52.28) (F [df ]
45.82 [1], P = 0.000); aggressive behavior subscale: ADHD
group (mean: 64.04; 95% CI: 62.06-66.02) vs. control group
(mean: 51.25; 95% CI: 49.36-53.15) (F [df ]: 70.46 [1], P
= 0.000); total score: ADHD group (mean: 64.85; 95% CI:
62.25-67.46) vs. control group (mean; 45.44:95% CI: 42.9547.93) (F [df ]: 94.01 [1], P = 0.000); internalizing problems
subscale: ADHD group (mean: 59.85; 95% CI: 56.74-62.96)
vs. control group (mean: 48.86; 95% CI: 45.88-51.84) (F
[df ]: 21.13 [1], P = 0.000); externalizing problems subscale:
ADHD group (mean: 62.70; 95% CI: 60.31-65.10) vs. control group (mean: 43.52; 95% CI: 41.23-45.81) (F [df ]:
108.50 [1], P = 0.000) (ANCOVA).
The variables that might influence SRS scores were evaluated in the ADHD group, and age at first word spoken, a
comorbid diagnosis, WISC-R total score, number of correct RMET answers, and CBCL attention problems subscale
score were analyzed using multiple linear regression. The

variables associated with SRS total score were the number of

correct RMET answers and CBCL attention problems subscale score; SRS total score increased as the CBCL attention
problems subscale score increased and the number of correct
RMET answers decreased (Table 4).

DISCUSSION and CONCLUSION

Interest in the social-emotional effects of ADHD, as well
as those that are behavioral, has been increasing; however,
there is a tendency for clinicians to overlook impaired social
functioning in those with ADHD, concentrating solely on
academic problems. In the present study the hypothesis that
ADHD may affect social communication skills was examined
based on social reciprocity and judgment of emotional expression in children diagnosed with ADHD.
CBCL, which was used in the present study, is widely used
to screen psychopathology in clinical settings and for epidemiological research (Petty et al. 2008). A study that evaluated
the CBCL subscales in a community sample reported that
there is a correlation between attention problems and social
problems (Bohlin and Janols 2004). It was also reported that
CBCL is a reliable tool for screening psychiatric disorders
in children diagnosed with ADHD, that the ADHD group
had a higher CBCL score than the control group, that the
primary symptoms of ADHD are concurrent with impaired
social, motor, and cognitive functioning, and psychiatric disorders, and that disorders that are comorbid with ADHD can
be diagnosed based on CBCL subscale scores (Cormier et al.
2008; Biederman et al., 2005). As such, in addition to clinical
evaluation, the CBCL attention problems subscale was used
as a criterion for comparing attention skills in the present
studys 2 groups and for determining the severity of attention
problems in the ADHD group. Consistent with the findings
reported by similar studies, in the present study all CBCL

subscale scores and total score were higher in the ADHD

group than in the control group (Grene et al. 1996). As expected, these findings support the notion that more children
with ADHD have social relationship and attention problems
than those without ADHD.
As such developmental milestones as speech and toilet training occurred later in the present studys ADHD group, intelligence levels were evaluated in both groups and the mean
level was lower in the ADHD group, though in both groups
the level was within the normal range. A study conducted
with preschool-age children reported that children diagnosed
with ADHD had lower scores than controls on developmental tests and that more of them had impaired behavioral,
social, and cognitive functioning (DuPaul et al. 2001). A
study on the psychometric definition of lack of social skills
in children diagnosed with ADHD reported that intelligence
scores in those with ADHD were lower than in controls, as
in the present study, but the correlation between intelligence
score and poor social skills was limited (Greene et al. 1996).
Previous studies have highlighted the impact of the level of
intelligence on social functioning, but detailed data are not
available (DuPaul et al. 2002; Greene et al. 1996).
In the present study social problems and attention problems
occurred more frequently in the children with ADHD, and
their cognitive skills were less advanced than those of the controls, which necessitates more detailed investigation of social/
emotional skills. Inappropriate emotional response and inability to understand emotions based on facial expressions, which
are among the diagnostic criteria for autistic disorder, are the
basis of social dysfunction (Guralnick 2005); therefore, in the
evaluation of social functioning in children with ADHD the
skill of judging emotions based on facial expressions has become important. In the present study the ADHD group correctly recognized fewer emotions based on facial expressions
than did the control group. Another study similarly reported
that in children with ADHD judgment of emotional expressions was inadequate and was associated with interpersonal
problems (Pelc et al. 2006). These findings may be due to
the symptoms of attention deficit and impulsivity, which are
considered the main characteristics of ADHD, as well as to
environmental factors (Sagvolden et al. 1998). In addition, it
was reported that poor performance by children with ADHD
on visual and auditory tests that require attention might be
related to impaired executive function (Sergeant et al. 2002).
Another explanation is that children with ADHD experience difficulties in many domains, such as writing, drawing,
and reading, and have weak visual perception, and that their
problem judging facial expressions may be due to poor visual
perception (Gillberg et al. 1998). It is thought that, although
it is a necessary step in interpersonal relationships, the ability
to recognize emotions based on facial expressions is not sufficient on its own for social functioning.

Social reciprocity is of critical importance for the quality of

life in children. Children with poor social skills have more
problems related to school, leisure activities, and relationships
with peers, siblings, and parents. It was reported that more
children diagnosed with ADHD had problematic peer relationships and had fewer one-on-one relationships than their
healthy peers of the same sex (Hoza et al. 1994). Among the
psychological disorders of childhood, a marked association exists between ADHD and impaired social functioning. A study
based on SRS reported that autistic characteristics occur more
frequently in ADHD cases than in controls (Reiersen et al.
2008). In the present study the ADHD group had a higher
mean SRS score than did the control group and 54.7% of
the children in the ADHD group experienced social problems at a sub-threshold level, which may been due to the specific structure of ADHD, i.e. a tendency to exhibit negative
and violence-prone behaviors, as well as excessive hyperactive
and impulsive behavior. In addition, another characteristic of children with ADHD is that they are easily distracted
and do not listen to others in social situations. It is thought
that this and other similar symptoms of attention deficit can
negatively affect a childs social relationships. Another theory
is that social problems emerge in those with ADHD due to
inadequate inner regulatory mechanisms (Stroes et al. 2003).
In the present study, even after adjusting for the difference in
intelligence level between the ADHD and control groups, the
ADHD group was observed to have insufficient social reciprocity and recognition of emotions based on facial expressions, and had a higher rate of social/behavioral problems.
These findings suggest that impaired social functioning in the
ADHD group was a function of the disorder rather than retarded intelligence and development.
In terms of the risk factors associated with impairment in
social functioning in the ADHD group, age, verbal developmental milestones, a comorbid diagnosis, and level of intelligence were not correlated. The level of social reciprocity
in the ADHD group was associated with the ability to recognized emotions based on facial expressions and the level
of social reciprocity decreased in the presence of attention
problems. A study on autistic characteristics in a community
sample reported that there was a strong relationship between
the number of correct RMET answers, and emotional reactivity and social skills (Voracek and Dressler 2006). As such, it
is thought that children diagnosed with ADHD have autistic
characteristics, such as difficulty recognizing emotions based
on facial expressions, and that such attention problems inhibit the development of perceptual/sensual skills.
In summary, in reciprocal relationships children with ADHD
have deficient perception, which negatively affects their social reciprocity, limiting their ability to react in a socially
appropriate manner to events and to adapt to present social
conditions. These children have few and problematic peer

relationships, and are regarded by their families as problem

children with a bad temperament. Implementation of interventional programs that target early social skills training in
an effort to prevent/limit impaired social functioning may
help to alleviate the negative social effects of the disorder in
adulthood. The efficiency of family training, judicious drug
treatment, and interventional programs need to be increased.
Interventions should take into consideration diseases comorbid with ADHD and if necessary, supplementary treatment
targeting these disorders must be included.

Baron-Cohen S, Wheelwright S, Hill J et al. (2001) The Reading the Mind in

the Eyes test revised version: a study with normal adults, and adults with
Asperger syndrome or high-functioning autism. J Child Psychol Psychiatry,
42: 24151.

The present studys strengths and limitations should be considered when interpreting the findings. One limitation of the
present study is that evaluation of social reciprocity did not
include other measures of indicators of social reciprocity such
as hobbies, and relationships and family interactions were not
investigated in detail. Incorporation of the observations of
teachers would have contributed to the examination of social
reciprocity in the school environment. Another limitation of
the present study is that the RMET was used despite a lack
of data concerning its reliability and validity. The reliability
of the RMET for use in Turkish children has not been determined and our pilot study determined that its Cronbachs
alpha coefficient was low (0.496), which suggests that it is
not a reliable test for determining the ability to recognize
emotions based on facial expressions; however, we think that
the inclusion of a control group might have compensated for
this. In the present study the ADHD group was evaluated
after drug treatment was discontinued, as it was thought that
perceptual skills may vary in those taking medication; therefore, the present findings may not be consistent with those
observed in children with ADHD taking medication. In addition, in order to not disrupt their treatment regime drugs
were discontinued for only 24 h. It is thought that the effect
of drugs with long half-lives may have continued during the
interview process. In conclusion, we think additional research
based on evaluations that include parameters associated with
social reciprocity will further our understanding of the effect
of ADHD on social reciprocity.

Constantino JN, PrzybeckT, Friesen D et al. (2000) Reciprocal social behavior

in children with and with out pervasive developmental disorders. J Dev
Behav Pediatr, 21: 2-11.

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