Executive function deficits contribute to poor theory of mind abilities in adults with ADHD

Emotion processing difficulties in ADHD: a Bayesian meta-analysis study

We investigated whether there is an emotional processing deficit in ADHD and whether this only applies to specific emotional categories. In this PRISMA-compliant systematic review based on a pre-registered protocol ( https://osf.io/egp7d ), we searched MEDLINE, PsycINFO, ERIC, Scopus and Web of Science databases until 3rd December 2023, to identify empirical studies comparing emotional processing in individuals meeting DSM (version III to 5-TR) or ICD (version 9 or 10) criteria for Attention Deficit/Hyperactivity Disorder (ADHD) and in a non-psychiatric control group. Study quality was assessed with the Appraisal tool for Cross-Sectional Studies (AXIS). Eighty studies were included and meta-analysed (encompassing 6191 participants and 465 observations). Bayesian meta-analyses were conducted to compare individuals with ADHD and non-psychiatric controls on overall emotional processing measures (meta-analysis 1) and across emotional categories (meta-analysis 2). The type of stimulus employed, outcome measurement reported, age, sex, and medication status were analysed as moderators. We found poorer performance in both overall emotion processing (g =  - 0.65) and across emotional categories (anger g =  - 0.37; disgust g =  - 0.24; fear g =  - 0.37; sadness g =  - 0.34; surprise g =  - 0.26; happiness/positive g =  - 0.31; negative g =  - 0.20; neutral g =  - 0.25) for individuals with ADHD compared to non-psychiatric controls. Scales items and accuracy outcome being the most effective moderators in detecting such differences. No effects of age, sex, or medication status were found. Overall, these results show that impaired emotional processing is a relevant feature of ADHD and suggest that it should be systematically assessed in clinical practice.

Facial Affect Recognition and Executive Function Abnormalities in ADHD Subjects: An ERP Study

Attention-deficit/hyperactivity disorder (ADHD) affects approximately 12% of children worldwide. With a 50% chance of persistence into adulthood and associations with impairments in various domains, including social and emotional ones, early diagnosis is crucial. The exact neural substrates of ADHD are still unclear. This study aimed to reassess the behavioral and neural metrics of executive functions and neural substrates of facial affect recognition. A total of 117 ADHD patients and 183 healthy controls were evaluated by two Go/NoGo tasks: the classic visual continuous performance test and the emotional continuous performance test, which requires facial affect encoding. Group differences between ADHD subjects and healthy controls were assessed using analysis of covariance (ANCOVA), with age and sex included as covariates. Dependent variables comprised behavioral (number of omission and commission errors, reaction time, and reaction time variability) and neurophysiological measures (event-related potentials [ERPs]). As the main result, we identified significant differences between ADHD patients and healthy controls in all behavioral metrics, one neural marker of action inhibition (P3d) and the facial processing marker (N170). The differences were moderate-to-large when expressed as effect size measures in behavioral variables and small-to-moderate for neurophysiological variables. The small-to-moderate effect sizes obtained from the neurophysiological measures suggest that ERPs are insufficient as sole markers for effectively screening emotion and face processing abnormalities in ADHD.

A Systematic Review on Social Cognition in ADHD: The Role of Language, Theory of Mind, and Executive Functions

Background: In this systematic review, conducted according to the PRISMA 2020 guidelines, we aimed to assess differences in the cognitive processes associated with social cognition-namely language, theory of mind (ToM), and executive functions (EFs)-between ADHD and control groups. Methods: The review included studies indexed in PubMed, Google Scholar, and PsycINFO up until May 2024. Eligible original peer-reviewed articles met the following criteria: they were written in English, included a clinical group with a current primary ADHD diagnosis, were empirical, included quantitative data, and utilized standardized and validated measures with adequate psychometric properties to assess social cognitive processes. Results and Discussion: A total of 1215 individuals with ADHD participated in the selected studies. Out of the 22 articles reviewed, 17 reported significant differences between ADHD and the controls across several cognitive processes related to language and EF rather than ToM. These processes included pragmatic skills, verbal and nonverbal communication, emotional prosody, interaction skills, sarcasm, paradoxical sarcasm recognition, ambiguous situations, emotion recognition, false belief, social problem solving, social behaviors, and gesture codification. We also discuss the limitations of the research and the implications of our findings. Systematic review registration: PROSPERO ID: CRD42023474681.

Neurocognitive and cerebellar function in ADHD, autism and spinocerebellar ataxia

The cerebellum plays a major role in balance, motor control and sensorimotor integration, but also in cognition, language, and emotional regulation. Several neuropsychiatric disorders such as attention deficit-hyperactivity disorder (ADHD), autism spectrum disorder (ASD), as well as neurological diseases such as spinocerebellar ataxia type 3 (SCA3) are associated with differences in cerebellar function. Morphological abnormalities in different cerebellar subregions produce distinct behavioral symptoms related to the functional disruption of specific cerebro-cerebellar circuits. The specific contribution of the cerebellum to typical development may therefore involve the optimization of the structure and function of cerebro-cerebellar circuits underlying skill acquisition in multiple domains. Here, we review cerebellar structural and functional differences between healthy and patients with ADHD, ASD, and SCA3, and explore how disruption of cerebellar networks affects the neurocognitive functions in these conditions. We discuss how cerebellar computations contribute to performance on cognitive and motor tasks and how cerebellar signals are interfaced with signals from other brain regions during normal and dysfunctional behavior. We conclude that the cerebellum plays a role in many cognitive functions. Still, more clinical studies with the support of neuroimaging are needed to clarify the cerebellum's role in normal and dysfunctional behavior and cognitive functioning.

Patterns of multiple brain network activation in dot perspective task

In this functional MRI (fMRI) study on 82 healthy adults using the dot perspective task, inconsistency of perspectives was associated with a significant increase of the mean reaction time and number of errors both in Self and Other conditions. Unlike the Arrow (non-mentalizing), the Avatar (mentalizing) paradigm was characterized by the recruitment of parts of the mentalizing and salience networks. These data provide experimental evidence supporting the fMRI distinction between mentalizing and non-mentalizing stimuli. A widespread activation of classical theory of mind (ToM) areas but also of salience network and decision making areas was observed in the Other compared to Self-conditions. Compared to Self-Consistent, Self-Inconsistent trials were related to increased activation in the lateral occipital cortex, right supramarginal and angular gyrus as well as inferior, superior and middle frontal gyri. Compared to the Other-Consistent, Other-Inconsistent trials yielded strong activation in the lateral occipital cortex, precuneus and superior parietal lobule, middle and superior precentral gyri and left frontal pole. These findings reveal that altercentric interference relies on areas involved in self-other distinction, self-updating and central executive functions. In contrast, egocentric interference needs the activation of the mirror neuron system and deductive reasoning, much less related to pure ToM abilities.

The relationship between executive function, neurodevelopmental disorder traits, and academic achievement in university students

Difficulties with executive function have often been identified in individuals with various neurodevelopmental disorders such as Autism Spectrum Disorder (ASD), Attention-Deficit Hyperactivity Disorder (ADHD), and Developmental Co-ordination Disorder (DCD). Additionally, in childhood and adolescence, executive functioning is an important predictor of academic achievement. However, less research has explored these relationships in adult students, and those with a high level of neurodevelopmental disorder traits but no clinical diagnosis. Therefore, the current study aimed to assess whether ASD, ADHD, and DCD traits can predict academic achievement in university students, and whether traits of these neurodevelopmental conditions moderate the relationship between executive function and academic achievement. Both neurotypical students and those with a clinical diagnosis of a neurodevelopmental disorder were able to participate, with the majority being neurotypical. Participants completed four self-report questionnaires and provided a measure of academic achievement based on their university assignment results. Traits of ASD, ADHD, and DCD alone did not predict achievement, however, traits of ADHD and DCD significantly moderated the relationship between executive function and academic achievement. ASD traits did not significantly moderate this relationship. Implications and suggestions for future research are also discussed.

Social Cognition in Adult ADHD: A Systematic Review

The aim of this systematic review was to collect and align the research on social cognition impairments in adults with Attention-deficit/hyperactivity disorder (ADHD). In particular, we selected and analyzed papers on emotion recognition and processing, Theory of Mind (TOM), empathy, and other facets of social cognition as decision making. We identified 16 papers published between 2012 and 2022 which meet inclusion criteria. Papers search, selection, and extraction followed the PRISMA guidelines. In order to summarize data from papers, we used a narrative synthesis approach. Results show different evidence of impairment in social cognition domains in adults with ADHD. Our systematic review suggests the importance of promoting more research on this topic because it is essential to keep in mind that social cognition plays a central role in socialization and social relationships.

Attentive-executive functioning and compensatory strategies in adult ADHD: A retrospective case series study

Background

Adults with ADHD exhibit a neuropsychological profile that may present deficits in many cognitive domains, particularly attention and executive functions (EFs). However, some authors do not consider executive disfunction as an important part of the clinical profile of the syndrome; this could be related to the use of inappropriate neuropsychological tests, probably not adapted and not sufficiently ecological. Moreover, new data are required on specific correlation of attentive-executive symptoms with socio-demographic factors. Therefore, the aim of this study is to analyze the neuropsychological performance of a group of adults with ADHD, also evaluating the influence of gender, age and education level.

Methods

We retrospectively collected health-related personal data of 40 adult ADHD patients, clinically diagnosed and evaluated via a battery of 4 neuropsychological tests and 1 self-administered questionnaire. Gender, age and years of education differences were assessed.

Results

Attention and EFs deficits have been highlighted mainly on the d2-R and 5-point neuropsychological tests, which therefore seem to be more sensitive in measuring the attention-executive dysfunction in an adult ADHD population, than TAP Go/No-go and ROCFT. ADHD patients also manifested subjective behavioral impulsivity disorders on BIS-11. There were no statistically significant gender differences in cognitive performance. On the contrary, younger patients performed worse on subscales TAP Go/No-go errors and 5-points number of drawings, while participants with a higher education level performed better on subscales d2-R speed of execution and d2-R errors. This supports a reduction in the number of errors and the execution time as a function of older age and a higher level of education. Finally, patients with higher education also self-reported greater impulsivity in planning.

Conclusion

Our preliminary findings suggest that adult ADHD is not a lifelong stable disorder, but it may change over time. Moreover, attention-executive deficits may be influenced and partially counterbalanced by experience (i.e., advancing age) and a higher level of education. This could underlie the development of specific psycho-behavioral and cognitive compensatory strategies. The use of self-administered questionnaires is therefore recommended to highlight attentional and executive difficulties that may not result in neuropsychological tests.

Basic and complex cognitive functions in Adult ADHD

Background

Many clinical studies reported deficits in basic and complex cognitive functions in adults with Attention-Deficit/Hyperactivity Disorder (ADHD). However, the extent in which deficits in basic functions (i.e., processing speed and distractibility) contribute to complex cognitive impairments (i.e., working memory, planning, cognitive flexibility, memory functions) in adults with ADHD is not well-studied. So far, literature show only one study, revealing that basic functions explain 27–74% of executive dysfunctions. Yet, the authors reported that findings could be affected by the selection of neuropsychological tests. The goal of the present research is to replicate such a finding using a different sample and a different set of neuropsychological tests.

Methods

Forty-eight adult patients with ADHD were compared with 48 healthy controls in basic cognitive functions, namely processing speed and distractibility and more complex cognitive functions, namely selective attention, cognitive flexibility, planning, working memory, verbal fluency, and verbal memory. Basic and complex cognitive functions were assessed using the Vigilance and Sustained Attention, Selective Attention, N-Back, Tower of London, Trail Making Test, Word Fluency, and Verbal Learning and Memory.

Results and conclusion

Logistic regression analyses showed that impairments in complex cognitive functions explained 25% of the variance in ADHD diagnosis. The explained variance dropped from 25% to 9% after considering basic functions of processing speed and distractibility. This 64% reduction highlights the importance of basic functions for impairments in complex functions in patients with ADHD.

Examining the roles of cognitive flexibility, emotion recognition, and metacognitions in adult Attention Deficit and Hyperactivity Disorder with predominantly inattentive presentation

The evaluation of cognitive functions in Attention Deficit and Hyperactivity Disorder (ADHD) is fundamental to improve the efficacy of therapeutic interventions. However, the role of specific higher-order cognitive functions in adult ADHD, including cognitive flexibility, emotion recognition, and metacognitions, remains unclear. Therefore, in the current study, we aimed to examine these three distinct higher-order cognitive functions among adult ADHD individuals. Forty patients with ADHD with predominantly inattentive presentation and 42 healthy controls participated in the study. The Adult Attention Deficit and Hyperactivity Disorder Scale (AADHDS), the Wisconsin Card Sorting Test (WCST), the Reading the Mind in the Eyes Test (RMET), and the Metacognitions Questionnaire-30 (MCQ-30) were administered. Results indicated that patients with ADHD had worse metacognitions scores, in specific subdimensions, relative to healthy controls. However, cognitive flexibility and emotion recognition did not differ between the groups. Moreover, the cognitive confidence subdimension of the MCQ-30 was found to be sole significant predictor in the attention deficit subdimension of the AADHDS. Our findings suggest that lack of cognitive confidence may contribute to ADHD symptomatology despite regularly functioning cognitive flexibility and emotion recognition. Therefore, metacognitions could be a suitable target to alleviate the severity of ADHD symptoms.

Cognitive characterization of adult attention deficit hyperactivity disorder by domains: a systematic review

Attention deficit hyperactivity disorder (ADHD) is reportedly the most frequent neurodevelopmental disorder diagnosed during childhood, and it is recognized as a common condition in adulthood. We review the evidence to help identify cognitive domains associated to deficits in adult ADHD. A systematic review with narrative synthesis was performed, assessing studies on adult ADHD, neuropsychology and research on involved cognitive domains in adults 18+ years old with an established diagnosis of ADHD, in seven electronic databases (PubMed, PsychInfo, WebOfScience, Embase, Scopus, OvidSPMedline, and Teseo), and Worldcat and OpenGrey grey literature databases. 93 studies were included for this review, encompassing findings from a total 5574 adults diagnosed only with ADHD, medication-naïve or non-medicated at the moment of the assessment and 4880 healthy controls. Adults diagnosed with ADHD may show, when compared to healthy controls, a cognitive profile characterized by deficits across all attention modalities, processing speed, executive function (mainly working memory and inhibition with emphasis on reward delay and interference control), verbal memory, reading skills, social cognition and arithmetic abilities. A cognitive characterization of adult ADHD by domains is established beyond the sole consideration of attention and executive function problems. Along with these, verbal memory, language (mainly reading), social cognition and arithmetic abilities may also contribute to a more comprehensive characterization of the cognitive profile in adult ADHD.

Neural Correlates of Theory of Mind in Autism Spectrum Disorder, Attention-Deficit/Hyperactivity Disorder, and the Comorbid Condition

Theory of mind (ToM) or mentalizing difficulties is reported in attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD), but the mechanism underpinning these apparently shared deficits is relatively unknown. Eighty-three young adult males, 19 with ASD alone, 21 with ADHD alone, 18 with dual diagnosis of ASD and ADHD, and 25 typically developing (TD) controls completed the functional magnetic resonance imaging version of the Frith-Happé animated-triangle ToM task. We compared neural function during ToM with two non-ToM conditions, random and goal directed motions, using whole-brain and region-of-interest analysis of brain activation and functional connectivity analyses. The groups showed comparable ToM task performance. All three clinical groups lacked local connectivity increase shown by TD controls during ToM in the right temporoparietal cortex, a key mentalizing region, with a differentially increased activation pattern in both ASD and comorbid groups relative to ADHD. Both ASD groups also showed reduced connectivity between right inferior lateral prefrontal and posterior cingulate cortices that could reflect an atypical information transmission to the mentalizing network. In contrast, with mentalizing both ADHD groups showed decreasing connectivity between the medial prefrontal and left temporoparietal cortices when compared to TD controls. Therefore, despite the complex pattern of atypical brain function underpinning ToM across the three disorders, some neurofunctional abnormalities during ToM are associated with ASD and appeared differentiable from those associated with ADHD, with the comorbid group displaying combined abnormalities found in each condition.

Reading the Mind in the Eyes Test: Relationship with Neurocognition and Facial Emotion Recognition in Non-Clinical Youths

OBJECTIVE

The Reading the Mind in the Eyes Test (RMET) is a common measure of the Theory of Mind. Previous studies found a correlation between RMET performance and neurocognition, especially reasoning by analogy; however, the nature of this relationship remains unclear. Additionally, neurocognition was shown to play a significant role in facial emotion recognition. This study is planned to examine the nature of relationship between neurocognition and RMET performance, as well as the mediating role of facial emotion recognition.

METHODS

One hundred fifty non-clinical youths performed the RMET. Reasoning by analogy was tested by Raven's Standard Progressive Matrices (SPM) and facial emotion recognition was assessed by the Korean Facial Expressions of Emotion (KOFEE) test. The percentile bootstrap method was used to calculate the parameters of the mediating effects of facial emotion recognition on the relationship between SPM and RMET scores.

RESULTS

SPM scores and KOFEE scores were both statistically significant predictors of RMET scores. KOFEE scores were found to partially mediate the impact of SPM scores on RMET scores.

CONCLUSION

These findings suggested that facial emotion recognition partially mediated the relationship between reasoning by analogy and social cognition. This study highlights the need for further research for individuals with serious mental illnesses.