Research in Developmental Disabilities 35 (2014) 3191–3198

Contents lists available at ScienceDirect

Research in Developmental Disabilities

Social cognition in ADHD: Irony understanding and recursive

theory of mind
Stéphanie Caillies a,*, Vincine Bertot a,b, Jacques Motte b, Christine Raynaud b,
Michel Abely b
a
Cognition, Health and Socialisation Laboratory (EA 6291), University of Reims Champagne Ardenne, 57 rue Pierre Taittinger,
51096 Reims Cedex, France
b
Department of Paediatrics, American Memorial Hospital, Reims University Hospital, 47 Rue Cognacq-Jay, 51092 Reims Cedex, France

A R T I C L E I N F O A B S T R A C T

Article history: The main goal of the present study was to characterise the social cognition abilities of
Received 11 April 2014 French children with ADHD, in terms of their understanding of people’s recursive mental
Received in revised form 30 July 2014 states and their irony comprehension. We hypothesised that these children have difficulty
Accepted 4 August 2014
understanding second-order false beliefs and ironic remarks, owing to the executive
Available online
dysfunction that is characteristic of ADHD. We therefore conducted an experiment in
which children with ADHD and typically developing matched controls performed second-
Keywords:
order false-belief and executive function tasks. They then listened to ironic stories and
ADHD
Theory of mind answered questions about the ironic comments and about the speakers’ beliefs and
Irony attitudes. The groups differed significantly on second-order theory of mind, irony
Executive functions comprehension and executive functions, confirming that children with ADHD have
Pragmatics impaired social cognition.
ß 2014 Elsevier Ltd. All rights reserved.

1. Introduction

Attention deficit hyperactivity disorder (ADHD) is one of the most prevalent neurodevelopmental disorders in childhood.
It is associated with impaired functioning not only in cognitive and academic domains, but in social ones, too (Barkley, 2003).
Children with ADHD appear to display inadequate social behaviour (for a review, see Nijmeijer et al., 2008) and to have
impaired social cognition (Uekermann et al., 2010). Social cognition can be briefly defined as the ability to understand other
people’s minds and, more specifically, to perceive emotion, empathise, attribute false belief and understand intended
meaning, among others. Although deficits in the social cognition domain are clinically observed in ADHD, little research has
been carried out in this area – a situation the present study sought to remedy. Some authors have reported social cognition
difficulties in children with ADHD, specifically in emotion perception and/or processing (Pelc, Kornreich, Foisy, & Dan, 2006;
Sinzig, Morsch, & Lehmkuhl, 2008), empathy (Braaten & Rosén, 2000; Dick, Ferguson, & Shochet, 2001; Marton, Wiener,
Rogers, Moore, & Tannock, 2009), theory of mind (ToM; Gonzalez-Gadea et al., 2013; Ibáñez et al., 2011) and pragmatics

* Corresponding author at: C2S, EA 6291, Université de Reims Champagne-Ardenne, 57 rue Pierre Taittinger, 51096 Reims Cedex, France.
Tel.: +33 03 26 91 36 37; fax: +33 03 26 91 37 09.
E-mail address: stephanie.caillies@univ-reims.fr (S. Caillies).

http://dx.doi.org/10.1016/j.ridd.2014.08.002
0891-4222/ß 2014 Elsevier Ltd. All rights reserved.
3192 S. Caillies et al. / Research in Developmental Disabilities 35 (2014) 3191–3198

(Bignell & Cain, 2007; Camarata & Gibson, 1999; Geurts & Embrechts, 2008; Staikova, Gomes, Tartter, McCabe, & Halperin,
2013). The present study sought to further investigate both pragmatic language abilities and ToMin children with ADHD.
Pragmatics refers to the use and comprehension of language in context, rather than to the semantic or structural aspects of
language. It involves skills such as using contextual information to interpret incoming utterances and understand implicit
messages or figurative expressions (Grice, 1989). Among the different types of figurative language, irony is a common and
frequently occurring figure of speech that is used to convey speakers’ beliefs and attitudes to situational events, and thus
serves a variety of social and communicative functions (Gibbs & Colston, 2012). In this sense, irony comprehension is a useful
indicator of pragmatic abilities. Understanding an ironic utterance necessarily requires pragmatic inferences to be drawn
from the context. For example, saying ‘‘He is bright’’ about an idiot can only be understood as ironic from the context. The
literature on the development of irony comprehension suggests that recognition of irony begins at around 6 years of age.
More specifically, this is when children start to detect that an ironic speaker does not believe what he/she has literally said
(Ackerman, 1981; Andrews, Rosenblatt, Malkus, Gardner, & Winner, 1986; Winner & Leekam, 1991), although this does not
mean that they necessarily understand all the components involved in irony comprehension, such as the speaker’s attitude.
Researchers have shown that the understanding of speakers’ beliefs precedes that of speakers’ attitudes (Ackerman, 1983;
Andrews et al., 1986). It has also been suggested that children’s understanding of a speaker’s ironic intent depends on their
cognitive ToM abilities (Filippova & Astington, 2008; Sullivan, Winner, & Hopfield, 1995). Once they have acquired a capacity
for second-order mental state reasoning, children are likely to use the speaker’s beliefs about the listener’s (or target’s)
beliefs as cues to interpretation. As such, the ability to make inferences about other people’s minds creates the possibility of
irony detection.
In the literature, there has yet to be any research on the irony comprehension of children with ADHD, and rare are the
studies that have investigated cognitive ToM abilities. Cognitive ToM is generally explored via false-belief tasks. The
standard version of these tasks involves the unexpected transfer of a desired object, so that the protagonist entertains a false
belief about the location of that object (Wimmer & Perner, 1983). Findings indicate that healthy children are able to
successfully perform first-order false-belief tasks at around 4 years (e.g., Flavell, Flavell, & Green, 1983; Hogrefe, Wimmer, &
Perner, 1986; Perner, Leekman, & Wimmer, 1987). However, they are unable to successfully complete second-order false-
belief tasks, which involve the comprehension of recursive mental states (e.g., John thinks that Mary thinks that. . .), until
they are about 6 or 7 years old (Coull, Leekam, & Bennett, 2006; Perner & Wimmer, 1985). To our knowledge, only three
studies have investigated false-belief understanding in children diagnosed with ADHD, and these have yielded divergent
results. Sodian and Hülsken (2005) found a significant difference between children with ADHD and their controls on a test of
advanced false-belief understanding that required them to represent the protagonists’ informational access. However, they
did not find any difference between these children and their controls on the Strange Story test (Happe, 1994). Charman,
Carrol, and Sturge (2001) also failed to find any significant difference between ADHD and control groups on the Strange Story
test. Finally, Buitelaar, Van der Wees, Swaab-barneveld, and van der Gaag (1999) reported a significant difference on second-
order false-belief understanding between a clinical subsample of nine children with ADHD and 11 psychiatric control
children, unlike Sodian and Hülsken (2005). Hence, children with ADHD may encounter problems with false-belief tasks –
problems that may also hinder irony understanding and, as a consequence, impair pragmatic abilities. Paradoxically, even
though the Strange Story test relies on figure-of-speech and irony understanding, children with ADHD have been shown not
to have difficulty with it (Charman et al., 2001; Sodian & Hülsken, 2005). Our study was intended to shed some light on these
inconsistencies.
It is important to explore the cognitive functions that may underlie social cognition deficits in ADHD. Social cognition
difficulties do not constitute the core symptom of ADHD which, according to the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV; American Psychiatric Association, 2000), is characterised by pervasive behavioural symptoms of
hyperactivity, impulsivity and inattention, beginning in childhood. Three subtypes of the disorder are identified in the
current clinical picture of ADHD offered in the DSM: predominantly inattentive, predominantly hyperactive-impulsive, and
combined types. Recent theories of ADHD highlight the role of executive functions (EFs) in the disorder (Barkley, 1997;
Castellanos, Sonuga-Barke, Milham, & Tannock, 2006; Willcutt, Doyle, Nigg, Faraone, & Pennington, 2005). EFs can be defined
as a set of general-purpose control mechanisms, often linked to the prefrontal cortex, that regulate the dynamics of human
cognition and action (Miyake & Friedman, 2012). There are generally agreed to be three core EFs: inhibitory control,
encompassing behavioural inhibition and interference control (selective attention and cognitive inhibition), working
memory (WM), and cognitive flexibility (Diamond, 2013). The debate about ADHD subtypes in terms of EF deficits (cf.
Desman, Petermann, & Hampel, 2008; Di Trani et al., 2011) does not fall within the ambit of this paper. Regarding typical
development, the finding that performances on false-belief tasks are correlated with performances on EF tasks is extremely
robust (see Perner & Lang, 1999, for a review), particularly for inhibitory control, even when chronological and mental age
are controlled for (Carlson & Moses, 2001; Carlson, Moses, & Breton, 2002; see also Flynn, 2007; Flynn, Malley, & Wood,
2004). Based on this evidence, we can hypothesise that the ToM deficits of children with ADHD are related to their inhibitory
control deficits. Consistent with this, Sodian and Hülsken (2005) found that ToM impairments come to light in tasks with
high inhibitory demands, and that children with ADHD are unimpaired on ToM tasks that do not require inhibitory control.
They therefore suggested that ToM itself remains intact, but there is a failure to express this ability in situations that require
inhibitory control. According to this rationale, a primary deficit in inhibitory control could lead to a failure to develop
particular ToM skills in comparison with typically developing peers and, as a consequence, to impaired pragmatic
processing, as inhibitory control is needed to understand irony. In accordance with the hypothesis of interrelations between
 S. Caillies et al. / Research in Developmental Disabilities 35 (2014) 3191–3198 3193

these three domains, namely ToM, EFs and pragmatic abilities, irony understanding has also been shown to be positively
related to executive functioning in children with cerebral palsy (Caillies, Hody, & Calmus, 2012).
In summary, as ADHD is a disorder that is associated with EF deficits, we hypothesised, based on the link suggested in the
literature between the three domains, that children with ADHD have deficits in both second-order ToM and irony
understanding. To test this hypothesis, we conducted an experiment in which children with ADHD and typically developing
matched controls performed ToM–specifically second-order false-belief tasks–and EF tasks. They also listened to ironic
stories and answered questions about the speakers’ beliefs and attitudes, and about why the ironic utterances had been
pronounced. We chose EF tasks that would tap into WM and inhibitory control, which are particularly relevant when
studying figurative language comprehension (maintaining two meanings and inhibiting the literal meaning) and false-belief
understanding (maintaining two perspectives and inhibiting reality). Additionally, we assessed children’s verbal reasoning
using the Similarities subtest of the Wechsler Intelligence Scale for Children (WISC-IV; Wechsler, 2005).

2. Method

2.1. Participants

A total of 30 French children took part in the study: 15 children with ADHD (five girls, 10 boys) and 15 matched typically
developing children. Informed parental consent was obtained for all the children in accordance with the guidelines set out in
French ethical legislation. The mean chronological age of each group was 9 years (range: 6; 7–10; 6 years, SD: 1; 3 years).
Children in the ADHD group were recruited from consecutive referrals to the Department of Paediatrics of the American
Memorial Hospital in Reims, where they had received their diagnosis. Their diagnosis had been made by a team of qualified
clinicians (a neuropaediatrician and child neuropsychologists) using DSM-IV-TR criteria (2000), behavioural questionnaires
and specific neuropsychological assessments. Children in the ADHD group presented minor neurological signs. Three of them
met the criteria for predominantly inattentive type, four for predominantly hyperactive-impulsive type, and eight for
combined type. All were treated with methylphenidate, but were taken off their medication the day before testing.
Children in the typically developing group were recruited from elementary schools in Reims. They had never met the
criteria either for ADHD or for any other psychiatric disorder, and were matched with the experimental group for age, sex,
school grade level, and nonverbal skills, as assessed on the Coloured Progressive Matrices (Raven, Court, & Raven, 1998).

2.2. Material

2.2.1. Theory of Mind (ToM) assessment

We used two second-order false belief tasks to assess ToM: the ice cream story (Perner & Wimmer, 1985) and the birthday
story (Tager-Flusberg & Sullivan, 1994). The ice cream story was presented in comic strip form. The children were told a story
involving two friends, John and Mary. John and Mary are independently informed that the ice-cream van has been
unexpectedly transferred to a new location, moving from the park to the church. Hence, both John and Mary know where the
van was, but there is a mistake in John’s second-order belief about Mary’s belief: John thinks that Mary thinks that the van is
still in the park. The children were asked successively: ‘‘Where will John look for Mary?’’ (Prediction question), ‘‘Why will
John look for Mary in the park?’’ (Explanation question), ‘‘Where is Mary?’’ (Control question), and ‘‘Where is the ice-cream
van?’’ (Reality question). The control and/or reality questions had to be answered correctly for points to be awarded for the
other two questions (1 point for each correct answer, i.e., max. 2 points).
For the birthday story, children were asked to listen to a story involving Peter, his Mum and his Grandma, and were told
that they would be asked questions throughout the story. The story can be summarised as follows: it is Peter’s birthday and
his Mum wants to surprise him with a puppy. She tells Peter that she has bought him a great toy for his birthday (Question 1
asked here), but Peter then finds the birthday puppy in the basement (Question 2 asked here). His Mum does not see him go
down to the basement. When Peter’s Grandma phones his Mum to find out what time the birthday party is, she asks her,
‘‘Does Peter know what you’ve really got him for his birthday?’’ (Question 3 asked here) After Mum has answered, Grandma
says, ‘‘What does Peter think you’ve got him for his birthday?’’ (Questions 4 and 5 asked here). Children were asked the
following questions: ‘‘What has Mum bought for Peter’s birthday?’’ (Question 1: control), ‘‘Does Peter know that his Mum’s
got him a puppy for his birthday?’’ (Question 2: first-order ignorance), ‘‘What does Mum say to Grandma?’’ (Question 3:
second-order ignorance), ‘‘What does Mum say to Grandma?’’ (Question 4: second-order false belief), ‘‘Why does Mum say
that?’’ (Question 5: justification). The control question had to be answered correctly for points to be awarded for the other
four questions (1 point for each correct answer, i.e., max. 4 points).

2.2.2. Assessment of irony comprehension

Sixteen ironic stories were created, each describing an everyday interaction between a child and another person, and
ending with an ironic comment made by one of the speakers. Each ironic story was matched with a story in which the last
sentence was modified to become literal. We created two lists, each containing eight ironic and eight literal stories, and each
featuring a different version of each story. For example, if the first list contained the ironic version of a story, the second one
contained its literal version. The participants were randomly assigned to one of the two lists (i.e., 16 stories).
3194 S. Caillies et al. / Research in Developmental Disabilities 35 (2014) 3191–3198

Table 1
Example of an ironic story with its set of questions.
Paul is happy because at long last he is allowed to choose a perfume on his own. At the perfume shop, he takes his time and chooses a very masculine
perfume. On his way home, he meets his friend Arthur and tells him what he has bought. Arthur, sniffing Paul, says ‘‘Ah, I was wondering where that
fusty smell was coming from’’. (Paul est heureux car il a enfin le droit de choisir son parfum tout seul. Au magasin, il prend le temps et achète un parfum
très masculin. Sur le chemin du retour, il rencontre son ami Arthur et lui raconte ce qu’il a acheté. Arthur dit en sentant Paul: « Ah, je me demandais d’où
venait cette odeur de moisi ».)
Explanation question
Why did Arthur say that? (Pourquoi Arthur dit cela?)
Speaker’s belief question
Did Arthur mean what he said? Did Arthur think that Paul smelled fusty? (Est-ce qu’Arthur pense ce qu’il dit? Est-ce qu’Arthur pense que Paul sent le
moisi?)
Speaker’s attitude question
According to you, was what Arthur said funny? Do you think Arthur was making fun of Paul? (Selon toi, ce que dit Arthur est amusant? Est-ce que tu
penses qu’Arthur se moque de Paul?).

Each story was followed by three kinds of test questions. The first question required an explanation of the ironic comment
(i.e., why did the child say that?). The second set contained two questions assessing the children’s comprehension of the
speaker’s beliefs. One point was awarded each time the children answered a question correctly. The third set contained two
questions probing the children’s comprehension of the speaker’s attitude. As with the second set, one point was awarded
each time children answered a question correctly. The maximum possible score for the speaker’s belief and speaker’s
attitude questions was 16 points, while it was 8 points for the explanation question. Examples of this material are provided
in Table 1.

2.2.3. Assessment of executive functions (EFs)

2.2.3.1. Working memory (WM). We administered the Digit Span Forward (DSF) and Digit Span Backwards (DSB) subtests of
the WISC-IV (Wechsler, 2005), and the Sentence Repetition subtest of the French version of the Development
NEuroPSYchological Assessment (NEPSY; Korkman, Kirk, & Kemp, 2003) to assess WM. In the DSF task, the children had
to repeat a series of numbers in the same order, while in the DSB task, they had to repeat the numbers in the reverse order. In
the Sentence Repetition task, children had to listen to a series of sentences of increasing complexity and length, and recall
each one immediately afterwards. We used the classic scoring method, and combined the raw scores from these tests to form
the single raw score used here.

2.2.3.2. Inhibitory control. Two subtests of the French version of the NEPSY (Korkman et al., 2003) were used to investigate
inhibitory control: Auditory Attention and Response Set, and Statue. For the Auditory Attention and Response Set, children
were asked to put an object in a box when they heard the appropriate target word. For example, the word ‘‘red’’ would
correspond to a red object, whereas the word ‘‘yellow’’ would not (interference part). We only recorded the children’s raw
scores for the interference part. In the Statue subtest, children were asked to maintain a body position with eyes closed
during a 75-second period and to inhibit the impulse to respond to sound distracters. We used the classic scoring method,
and combined the raw scores from both tests to form the single raw score used here.

2.2.4. Verbal reasoning

We administered the Similarities subtest of the WISC-IV (Wechsler, 2005) to assess verbal reasoning. In this task, children
have to explain how two different things (e.g., shirt and shoe) or concepts (e.g., anger and joy) can be alike. We awarded
scores of either 2, 1 or 0, depending on the quality of the responses.

2.3. Procedure

All the tests were administered to the participants individually, in the children’s schools or homes. The data were
collected by clinicians under the responsibility of the second author, who is a neuropsychologist. The entire testing session
lasted approximately two hours.

2.4. Statistical analysis

Statistica 9 was used for all data analyses, and we conducted analyses of variance (ANOVAs) to assess the effect of group
on ToM, irony comprehension, and EFs. We ran a one-way ANOVA on the mean number of correct answers on the ToM
battery, in addition to a x2 on the success rate. For the irony task, we ran three two-way ANOVAs (type of comment and
group): one on the mean number of correct answers to the explanation question; one on the mean number of correct
answers to the two speaker’s belief questions; and one for the two speaker’s attitude questions. Finally, we ran one-way
ANOVAs on performances on each set of EF tasks (WM and inhibitory control), and one on verbal reasoning performances.
For these multiple statistical tests, we applied the Bonferroni correction.
 S. Caillies et al. / Research in Developmental Disabilities 35 (2014) 3191–3198 3195

Table 2
Mean scores and standard deviations of children with ADHD and controls on the TOM, working memory, inhibitory control, and verbal reasoning tasks.

Children with ADHD Control children

Mean Standard deviation Mean Standard deviation

Theory of mind false belief 1 1.13 2.4 0.83

Working memory 28.73 6.53 39.60 4.60
Inhibitory control 50.80 17.14 82.60 12.28
Verbal reasoning 17.90 5.51 22.87 4.24

Table 3
Mean scores (and standard deviations) of children with ADHD and controls on the irony task as a function of type of comment (ironic vs. literal).

Type of comment Children with ADHD Control children

Ironic Literal Ironic Literal

Irony 3.13 6.60 6.47 7.60

Explanation (1.96) (1.55) (1.30) (0.51)
Irony 6.53 12.33 13.07 14.67
Speaker’s belief (3.98) (3.02) (3.43) (1.99)
Irony 4.73 12 7.80 12.80
Speaker’s attitude (3.86) (3.16) (4.62) (2.60)

Correlations between the indicators of social cognition skills (ToM, irony comprehension) and EFs, as well as literal
language understanding, verbal reasoning and age, were studied within each group by means of Pearson correlation
coefficients.

3. Results

3.1. Group effect

The mean scores (and standard deviations) of the children with ADHD and controls on the ToM, WM, inhibitory control
and verbal reasoning tasks are set out in Table 2. Table 3 contains the same statistical indicators for the irony task, as a
function of group and type of comment (ironic vs. literal).

3.1.1. Second-order false-belief understanding

The ANOVA indicated a significant effect of group, F(1, 28) = 14.91, p < 0.01, h2p = 0.53. Mean scores were significantly
lower for children with ADHD than for controls (see Table 2). Only five children with ADHD successfully completed the tasks
(score equal to or above 2), compared with 14 controls, x2(14) = 4.05, p < 0.05. It should be noted that the children with
ADHD who understood second-order false beliefs did not all meet the criteria for the same subtype (three combined, one
predominantly inattentive, one predominantly hyperactive-impulsive).

3.1.2. Irony comprehension

As expected, results for the explanations of the comments indicated a significant interaction between group and type of
comment (ironic vs. literal), F(1, 28) = 9.73, p < 0.05, h2p = 0.34. As shown in Table 3, children with ADHD provided poorer
explanations for the ironic comments than controls, who had equivalent scores for both types of comment. We found a
similar result for the understanding of speakers’ beliefs, F(1, 28) = 6.13, p < 0.05, h2p = 0.22, in that the mean number of
correct answers was lower in the irony condition than in the control condition, but only for the ADHD group. Results for the
understanding of speakers’ attitudes failed to reveal a significant interaction between group and type of comment, F(1,
28) = 1.31, ns. The only significant effect was the main effect of type of comment, F(1, 28) = 38.58, p < 0.01, h2p = 1.38. The
mean number of correct answers was low for both groups, suggesting that neither really understood the speakers’ attitudes
in the ironic stories.
The most salient results were that the children with ADHD had greater difficulty explaining the meaning of the ironic
comments and inferring the speakers’ beliefs than the controls. Another notable result was that the children with ADHD did
not find it any harder than controls to infer the speakers’ attitudes. Children in both groups had difficulty inferring the
speakers’ attitudes.

3.1.3. Executive functioning

As expected, we obtained a significant effect of group on WM, F(1, 28) = 27.78, p < 0.01, h2p = 0.99, and inhibitory control,
F(1, 28) = 34.11, p < 0.01, h2p = 1.22. Performances were significantly better for controls than for the children with ADHD (see
Table 2). These results show that children with ADHD have impaired WM and an inhibitory control deficit.
3196 S. Caillies et al. / Research in Developmental Disabilities 35 (2014) 3191–3198

Table 4
Pearson correlation coefficients between ToM scores, explanation and speaker’s belief scores (irony task), literal understanding scores, age in months,
working memory scores, inhibitory control scores, and verbal reasoning scores within each group.

Control children Children with ADHD

Irony Irony speaker’s ToM Literal Irony explanation Irony speaker’s ToM Literal
[4_TD$IF]explanation belief belief

Age 0.35 0.37 0.70** 0.30 0.03 0.09 0.45 0.28

Inhibitory control 0.62* 0.82** 0.31 0.05 0.05 0.06 0.19 0.24
Working memory 0.26 0.41 0.42 0.17 0.43 0.06 0.27 0.55*
Verbal reasoning 0.28 0.51 0.68** 0.11 0.69** 0.75** 0.68** 0.44
ToM 0.41 0.57* 0.19 0.58* 0.68** – 0.14
Literal 0–0.09 0–0.22 0.19 – 0.23 0.18 0.14 –

* p < 0.05.
** p < 0.01.

3.1.4. Verbal reasoning

Results showed a significant effect of group, F(1, 28) = 7.75, p < 0.05, h2p = 0.28, on verbal reasoning performances, as the
mean number of correct answers was significantly higher for controls than for children with ADHD (see Table 2).

3.2. Correlations

We calculated Pearson correlation coefficients to study the interrelationships between indicators of social cognition skills
(ToM, irony comprehension) and executive functioning, as well as literal understanding scores, verbal reasoning
performances, and age in months. As our ANOVAs had not revealed any significant difference between the performances of
controls versus children with ADHD on the understanding of speakers’ attitudes, we did not retain this factor. The Pearson
correlation coefficients are set out in Table 4.
We identified several interesting patterns. First, results indicated significant correlations between second-order ToM and
irony comprehension within both groups. More specifically, second-order false-belief scores were significantly correlated
with understanding of speakers’ beliefs, r = 0.57, p < 0.05 for the control group and r = 0.68, p < 0.01 for the ADHD group. The
correlation between ToM scores and explanations of the ironic comments was also significant, r = 0.58, p < 0.05, but only for
the ADHD group. It should be noted that ToM was not significantly correlated with literal understanding scores in either
group. There was an additional finding regarding second-order ToM: it was significantly correlated with verbal reasoning
scores in both groups, r = 0.68, p < 0.01 for the control group and r = 0.67, p < 01 for the ADHD group.
Second, results indicated a link between inhibitory control scores and irony comprehension, but only for controls, r = 0.62,
p < 0.05 for explanation of ironic comments and r = 0.82, p < 0.01 for understanding of speakers’ beliefs. In the children with
ADHD, however, the only cognitive scores related to irony comprehension were the verbal reasoning scores, r = 0.70, p < 0.01
for explanations and r = 0.72, p < 0.01 for speakers’ beliefs, which were not significantly correlated with literal
understanding. Finally, results indicated a significant link between WM scores and literal understanding, r = 0.55,
p < 0.05, but exclusively for the ADHD group.

4. Discussion

The main goal of the present study was to characterise the social cognition abilities of children with ADHD, by exploring
their understanding of people’s recursive mental states and their irony comprehension. We hypothesised that children with
ADHD have difficulty understanding second-order false beliefs and ironic remarks, owing to their characteristic executive
dysfunction. Our results confirmed that children with ADHD experience problems with recursive ToM and irony
understanding, in addition to their expected WM and inhibitory control deficits.
Consistent with Buitelaar et al. (1999) result, the children with ADHD in our sample performed poorly on the second-
order false-belief tasks. Only five of the 15 children with ADHD successfully completed the two ToM tasks, compared with 14
of the 15 controls. Similarly, results for irony comprehension showed that the children with ADHD performed worse than
expected for their age. This is consistent with the idea that incomplete or delayed recursive ToM affects irony
comprehension, specifically the ability to detect that an ironic speaker does not believe what he/she has literally said. This
idea was confirmed by the significant link we found between second-order false belief scores and speaker’s belief
understanding for both the children with ADHD and the typically developing children. It is important to emphasise that no
such link was found for the comprehension of literal remarks. Failure to infer speakers’ beliefs means failure to understand
irony (Filippova & Astington, 2008; Sullivan et al., 1995). Irony is not a specific rhetorical device only to be used in unusual
circumstances. Ironic language makes up 8% of all conversational turns in adults (Gibbs, 2000). Our study indicated that
although children with ADHD performed more poorly than controls, they could still understand some of the ironic remarks
and complete part of the recursive ToM task. Research on ToM has shown that compound scores yielded by multiple tasks,
are more stable and lead to more accurate measurements (Hughes et al., 2000). Although the two recursive ToM tasks we
 S. Caillies et al. / Research in Developmental Disabilities 35 (2014) 3191–3198 3197

chose to administer in our study have been extensively used in several published studies, they were not clearly characterised
in terms of their psychometric properties. Where characterizations do exist in the literature, they refer to different aspects of
ToM (see Blijd-Hoogewys, van Geert, Serra, & Minderra, 2008). The same remark can be made for the irony task we used.
Thus, the present finding could reflect the particularly slow development of social cognition abilities in children with ADHD,
and suggests that it might be useful for clinicians to foster this developmental process. Social cognition abilities need to be
explored further in ADHD using reliable tools, and the results could in turn inform the work of clinicians.
Although the children with ADHD performed more poorly on the WM and inhibitory control tasks than typically
developing children, our results were only partially compatible with the hypothesis that impaired social cognition, measured
here via ToM and irony comprehension, reflects executive difficulties. Our results confirmed the expected link between
inhibitory control and irony comprehension (Caillies et al., 2012) but only for control children. Furthermore, they failed to
reveal a significant link between executive performances and second-order false-belief understanding for either children
with ADHD or controls, which is at odds with the literature (Carlson & Moses, 2001; Flynn, 2007; Sodian & Hülsken, 2005). A
lack of statistical power can explain the nonsignificance of the link for controls, but not for the children with ADHD (Pearson
coefficients close to 0). In actual fact, it was verbal reasoning, not inhibitory control, that appeared to be related to ToM
performances within each group. Verbal reasoning must not be confused with language comprehension, as it was not
significantly related to literal understanding. These results suggest that children with ADHD may have difficulty with tasks
that demand verbal reasoning, such as the Similarities subtest, and irony and false-belief understanding. This idea is
confirmed by the additional significant correlation we found in the ADHD group, between verbal reasoning and irony
comprehension. Gremillion and Martel (2012) recently highlighted the relationship between semantic language and ADHD
symptoms. More specifically, they found that semantic language, as assessed with the Vocabulary subtest of the WISC-IV,
explained the association between ADHD symptoms and academic reading underachievement, which is often observed in
the ADHD population. Taken as a whole, these findings suggest that children with ADHD may have difficulties mobilising
world knowledge and forming new concepts, as well as reasoning about them, and these difficulties could have
repercussions on both social cognition and academic achievement.
To conclude, this study was an attempt to explore two aspects of social cognition in children with ADHD: ToM and irony
comprehension. Results clearly indicate that children with ADHD encounter problems with recursive ToM and irony
comprehension. However, the cognitive functions that may subtend these impairments need to be explored further. Our
results emphasised the potential role of verbal reasoning, but the limited sample size means that our results must be
interpreted with caution. Nonetheless, our study adds to existing knowledge of the social cognition abilities of children with
ADHD. As we have already mentioned, several dimensions appear to be involved, such as the understanding of others’ mental
states and the process of inferring the speaker’s intended meaning. Irony understanding is a potentially useful tool for
scrutinising the social cognition abilities of children with ADHD, in the sense that it involves the comprehension of speakers’
beliefs and attitudes – a prerequisite for successful interpersonal communication –, and should be addressed more broadly in
future research.

References

Ackerman, B. P. (1981). Young children’s understanding of a speaker’s intentional use of a false utterance. Developmental Psychology, 17, 472–480. http://
dx.doi.org/10.1037/0012-1649.17.4.472
Ackerman, B. P. (1983). Form and function in children’s understanding of ironic utterances. Journal of Experimental Child Psychology, 35, 487–508. http://dx.doi.org/
10.1016/0022-0965(83)90023-1
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (DSM-IV) (4th ed.). Washington DC: American Psychiatric Association
(APA).
Andrews, J., Rosenblatt, E., Malkus, U., Gardner, H., & Winner, E. (1986). Children’s abilities to distinguish metaphoric and ironic utterances from mistakes and lies.
Communication and Cognition, 19, 281–298.
Barkley, R. A. (1997). Behavioral inhibition, sustained attention, and executive functions: Constructing a unifying theory of ADHD. Psychological Bulletin, 121(1),
65–94.
Barkley, R. A. (2003). Attention-deficit/hyperactivity disorder. In E. J. Mash & R. A. Barkley (Eds.), Child psychopathology (2nd ed., pp. 75–143). New York, NY:
Guilford Press.
Bignell, S., & Cain, K. (2007). Pragmatic aspects of communication and language comprehension in groups of children differentiated by teacher ratings of
inattention and hyperactivity. British Journal of Developmental Psychology, 25(4), 499–512. http://dx.doi.org/10.1348/026151006X171343
Braaten, E. B., & Rosén, L. A. (2000). Self-regulation of affect in attention deficit-hyperactivity disorder (ADHD) and non-ADHD boys: Differences in empathic
responding. Journal of Consulting and Clinical Psychology, 68(2), 313–321.
Blijd-Hoogewys, E. M., van Geert, A., Serra, P. L. C., & Minderra, M. R. B. (2008). Measuring theory of mind in children. Psychometric properties of the ToM
storybooks. Journal of Autism and Developmental Disorders, 38, 1907–1930. http://dx.doi.org/10.1007/s10803-008-0585-3
Buitelaar, J. K., Van der Wees, M., Swaab-barneveld, H., & van der Gaag, R. J. (1999). Verbal memory and performance IQ predict theory of mind and emotion
recognition ability in children with autistic spectrum disorders and in psychiatric control children. Journal of Child Psychology and Psychiatry, 40(6), 869–881.
Caillies, S., Hody, A., & Calmus, A. (2012). Theory of mind and irony comprehension in children with cerebral palsy. Research in Developmental Disabilities, 33, 1380–
1388. http://dx.doi.org/10.1016/j.ridd.2012.03.012
Carlson, S. M., Moses, L. J., & Breton, C. (2002). How specific is the relation between executive function and theory of mind? Contributions of inhibitory control and
working memory. Infant and Child Development, 92, 73–92. http://dx.doi.org/10.1002/icd
Carlson, S. M., & Moses, L. J. (2001). Individual differences in inhibitory control and children’s theory of mind. Child Development, 72(4), 1032–1053. http://
dx.doi.org/10.1111/1467-8624.00333
Camarata, S. M., & Gibson, T. (1999). Pragmatic language deficits in attention/deficit hyperactivity disorder. Mental Retardation and Developmental Disabilities
Research Reviews, 5, 207–214. http://dx.doi.org/10.1002/(SICI)1098-2779(1999)5:3<207::AID-MRDD7>3.0.CO;2-O
Castellanos, F. X., Sonuga-Barke, E. J. S., Milham, M. P., & Tannock, R. (2006). Characterizing cognition in ADHD: Beyond executive dysfunction. Trends in Cognitive
Sciences, 10(3), 117–123. http://dx.doi.org/10.1016/j.tics.2006.01.011
3198 S. Caillies et al. / Research in Developmental Disabilities 35 (2014) 3191–3198

Charman, T., Carrol, F., & Sturge, C. (2001). Theory of mind, executive function and social competence in boys with ADHD. Emotional and Behavioral Difficulties, 6(1),
31–49. http://dx.doi.org/10.1177/1363275201006001004
Coull, G. J., Leekam, S. R., & Bennett, M. (2006). Simplifying second order belief attribution: What facilitates children’s performance on measures of conceptual
understanding? Social Development, 15, 548–563. http://dx.doi.org/10.1111/j.1467-9507.2006.00357.x
Diamond, A. (2013). Executive functions. Annual Review of Psychology, 64, 135–168. http://dx.doi.org/10.1146/annurev-psych-113011-143750
Desman, C., Petermann, F., & Hampel, P. (2008). Deficit in response inhibition in children with attention deficit/hyperactivity disorder (ADHD): Impact of
motivation? Child Neuropsychology, 14(6), 483–503. http://dx.doi.org/10.1080/09297040701625831
Di Trani, M., Casini, M. P., Capuzzo, F., Gentile, S., Bianco, G., Menghini, D., et al. (2011). Executive and intellectual functions in attention-deficit/hyperactivity
disorder with and without comorbidity. Brain & Development, 33(6), 462–469. http://dx.doi.org/10.1016/j.braindev.2010.06.002
Dick, M. J., Ferguson, K., & Shochet, I. M. (2001). Do autism spectrum disorders differ from each other and from non-spectrum disorders on emotion recognition
tests? European Child and Adolescent Psychiatry, 10, 105–116.
Flynn, E. (2007). The role of inhibitory control in false belief understanding. Infant and Child Development, 69, 53–69. http://dx.doi.org/10.1002/icd
Flynn, E., Malley, C. O., & Wood, D. (2004). A longitudinal, microgenetic study of the emergence of false belief understanding and inhibition skills. Developmental
Sciences, 7(1), 103–115. http://dx.doi.org/10.1111/j. 1467-7687.2004.00326.x
Geurts, H. M., & Embrechts, M. (2008). Language profiles in ASD, SLI, and ADHD. Journal of Autism and Developmental Disorders, 38(10), 1931–1943. http://
dx.doi.org/10.1007/s10803-008-0587-1
Gibbs, R. W. (2000). Irony in talk among friends. Metaphor and Symbol, 15, 5–27. http://dx.doi.org/10.1207/S15327868MS151&2_2
Gremillion, M. L., & Martel, M. M. (2012). Semantic language as a mechanism explaining the association between ADHD symptoms and reading and mathematics
underachievement. Journal of Abnormal Child Psychology, 40(8), 1339–1349. http://dx.doi.org/10.1007/s10802-012-9650-7
Gonzalez-Gadea, M. L., Baez, S., Torralva, T., Castellanos, F. X., Rattazzi, A., Bein, V., et al. (2013). Cognitive variability in adults with ADHD and AS: Disentangling
the roles of executive functions and social cognition. Research in Developmental Disabilities, 34(2), 817–830. http://dx.doi.org/10.1016/j.ridd.2012.11.009
Grice, H. P. (1989). Studies in the way of words. Cambridge, MA: Harvard University Press.
Gibbs, R. W., & Colston, H. L. (2012). Interpreting figurative meaning. New York: Cambridge University Press.
Happe, F. (1994). An advanced test of theory of mind: Understanding of story characters’ thoughts and feelings by able autistic, mentally handicapped, and normal
children and adults. Journal of Autism and Developmental Disorders, 2, 129–154.
Hughes, C., Adlam, A., Happé, F., Jackson, J., Taylor, A., & Caspi, A. (2000). Good test–retest reliability for standard and advanced false belief tasks across a wide
range of abilities. Journal of Child Psychology and Psychiatry, 41, 483–490. http://dx.doi.org/10.1111/1469-7610.00633
Filippova, E., & Astington, J. W. (2008). Further development in social reasoning revealed in discourse irony understanding. Child Development, 79, 126–138. http://
dx.doi.org/10.1111/j. 1467-8624.2007.01115.x
Flavell, J. H., Flavell, E. R., & Green, F. L. (1983). Development of the appearance – Reality distinction. Cognitive Psychology, 15, 95–120.
Hogrefe, G. J., Wimmer, H., & Perner, J. (1986). Ignorance versus false belief: A developmental lag in attribution of epistemic states. Child Development, 57(3), 567–
582. http://dx.doi.org/10.2307/1130337
Ibáñez, A., Petroni, A., Urquina, H., Torrente, F., Torralva, T., Hurtado, E., et al. (2011). Cortical deficits of emotional face processing in adults with ADHD: Its relation
to social cognition and executive function. Social Neurosciences, 1, 1–18. http://dx.doi.org/10.1080/17470919.2011.620769
Korkman, M., Kirk, U., & Kemp, S. (2003). NEPSY: Bilan neuropsychologique de l’enfant. Paris: Editions du Centre de Psychologie Appliquée.
Marton, I., Wiener, J., Rogers, M., Moore, C., & Tannock, R. (2009). Empathy and social perspective taking in children with attention-deficit/hyperactivity disorder.
Journal of Abnormal Child Psychology, 37(1), 107–118. http://dx.doi.org/10.1007/s10802-008-9262-4
Miyake, A., & Friedman, N. P. (2012). The nature and organization of individual differences in executive functions: Four general conclusions. Current Directions in
Psychological Science, 21(1), 8–14. http://dx.doi.org/10.1177/0963721411429458
Nijmeijer, J. S., Minderaa, R. B., Buitelaar, J. K., Mulligan, A., Hartman, C. A., & Hoekstra, P. J. (2008). Attention-deficit/hyperactivity disorder and social
dysfunctioning. Clinical Psychology Review, 28(4), 692–708. http://dx.doi.org/10.1016/j.cpr.2007.10.003
Pelc, K., Kornreich, C., Foisy, M.-L., & Dan, B. (2006). Recognition of emotional facial expressions in attention-deficit hyperactivity disorder. Pediatric Neurology,
35(2), 93–97. http://dx.doi.org/10.1016/j.pediatrneurol.2006.01.014
Perner, J., & Lang, B. (1999). Development of theory of mind and executive control. Trends in Cognitive Sciences, 3(9), 337–344.
Perner, J., & Wimmer, H. (1985). John thinks that Mary thinks that: Attribution of second order beliefs by 5- to 10-year-old children. Journal of Experimental Child
Psychology, 39, 437–471. http://dx.doi.org/10.1016/0022-0965(85)90051-7
Perner, J., Leekman, S., & Wimmer, H. (1987). Three year-olds’ difficulty with false belief: The case for a conceptual deficit. British Journal of Developmental
Psychology, 5, 125–137. http://dx.doi.org/10.1111/j.2044-835X.1987.tb01048.x
Raven, J., Court, C., & Raven, J. H. (1998). Progressive Matrices Couleurs (PM38). Paris: Editions du Centre de Psychologie Appliquée.
Sinzig, J., Morsch, D., & Lehmkuhl, G. (2008). Do hyperactivity, impulsivity and inattention have an impact on the ability of facial affect recognition in children with
autism and ADHD? European Child & Adolescent Psychiatry, 17(2), 63–72. http://dx.doi.org/10.1007/s00787-007-0637-9
Sodian, B., & Hülsken, C. (2005). The developmental relation of theory of mind and executive functions: A study of advanced theory of mind abilities in children
with attention deficit hyperactivity disorder. In W. Schneider, R. Schumann-Hengsteler, & B. Sodian (Eds.), Young children’s cognitive development:
Interrelationships among executive functioning, working memory, verbal ability, and theory of mind (pp. 175–187). Mahwah, NJ: Lawrence Erlbaum Associates.
Staikova, E., Gomes, H., Tartter, V., McCabe, A., & Halperin, J. M. (2013). Pragmatic deficits and social impairment in children with ADHD. Journal of Child Psychology
and Psychiatry and Allied Disciplines, 54(12), 1275–1283. http://dx.doi.org/10.1111/jcpp.12082
Sullivan, K., Winner, E., & Hopfield, N. (1995). How children tell a lie from a joke: The role of second-order mental state attributions. British Journal of Developmental
Psychology, 13, 191–204. http://dx.doi.org/10.1111/j.2044-835X.1995.tb00673.x
Tager-Flusberg, H., & Sullivan, K. (1994). A second look at second-order belief attribution in autism. Journal of Autism and Developmental Disorders, 24, 577–586.
http://dx.doi.org/10.1007/BF02172139
Uekermann, J., Kraemer, M., Abdel-Hamid, M., Schimmelmann, B. G., Hebebrand, J., Daum, I., et al. (2010). Social cognition in attention-deficit hyperactivity
disorder (ADHD). Neuroscience and Biobehavioral Reviews, 34(5), 734–743. http://dx.doi.org/10.1016/j.neubiorev.2009.10.009
Wechsler, D. (2005). WISC-IV. Échelle d’intelligence de Wechsler pour enfants (Quatrième édition). Paris: Editions du Centre de Psychologie Appliquée.
Willcutt, E. G., Doyle, A. E., Nigg, J. T., Faraone, S., & Pennington, V. B. F. (2005). Validity of the executive function theory of attention-deficit/hyperactivity disorder:
A meta-analytic review. Biological Psychiatry, 57(11), 1336–1346. http://dx.doi.org/10.1016/j.biopsych.2005.02.006
Wimmer, H., & Perner, J. (1983). Beliefs about beliefs: Representation and constraining function of wrong beliefs in young children’s understanding of deception.
Cognition, 13, 103–128.
Winner, E., & Leekam, S. (1991). Distinguishing irony from deception: Understanding the speaker’s second-order intention. British Journal of Developmental
Psychology, 9, 257–270. http://dx.doi.org/10.1111/j.2044-835X.1991.tb00875.x