COGNITIVE AND EMOTIONAL IN ADOLESCENTS WITH ADHD: ARE

COMORBIDITIES, GENDER, AND PARENTAL -REJECTION

IMPORTANT FACTORS?

A dissertation submitted to the Kent State University College of Nursing in partial fulfillment of

the requirements for the degree of Doctor of Philosophy

By

Ghada Shahrour

December, 2017

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Dissertation written by

Ghada Shahrour

BSN, Jordan University of Science and Technology, 2006

M.S., Kent State University, 2011

Ph.D., Kent State University, 2017

Approved by

______, Chair, Doctoral Dissertation Committee Wendy Umberger ______, Member, Doctoral Dissertation Committee Andrea Warner-Stidham ______, Member, Doctoral Dissertation Committee Marlene Huff ______, Member, Doctoral Dissertation Committee Beth Wildman ______, Member, Doctoral Dissertation Committee Sarah Delahanty Accepted by

______, Director, Joint Ph.D. in Nursing Program Patricia Vermeersch ______, Graduate Dean, College of Nursing Wendy Umberger ii

ACKNOWLEDGEMENTS

I would like to extend my grateful appreciations to my advisor, Dr. Wendy Umberger whom without her extensive knowledge in research and brilliant intelligence I would not be able to produce this dissertation. Dr. Wendy assisted me in developing and sharpening my research ideas, organizing my research work, and to think analytically through providing productive feedback, comments, and suggestions. I’m very grateful as well to her continuous support and encouragement throughout my journey in the Ph.D. program.

I would like to thank all of my committee members and specifically Dr. Sarah Delahanty, who walked me through the IRB process at Akron Children’s Hospital and supervised this lengthy process. Many thanks to Tara Clemas, the nurse at the Neurodevelopmental and Science Center of Akron Children’s Hospital who volunteered to collect my data in her facility.

Many grateful thanks to the staff at Children’s Advantage, my second site for data collection.

I’m very grateful to all of the help I received from Dr. Winnie Sprague, Carla Burnfield, Vicki

Young, Lisa, Pat, and Dr. Thomas.

I would like to thank my family who supported me throughout my journey and were with me step by step; thank you my dad and my mom, my lovely sisters Saeda, Bayan, and Aya and my wonderful brothers, Ashraf, Fawaz, and Ahmad. Thank you all for your prayers and your in me. I don’t want to forget my awesome friends who also gave me all of the support I needed and who had and faith in my ability to accomplish my scholarly achievement.

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Table of Contents

Page CHAPTER 1: INTRODUCTION ……………………………………………………………… 1 Background and Significance ……………………………………………………………... 2 Theoretical Framework ……………………………………………………………………. 7 Significance to Nursing ……………………………………………………………………. 9

CHAPTER 2: REVIEW OF THE LITERATURE …………………………………………….. 12 Background on ADHD ……………………………………………………………………..13 Prevalence, Etiologies, and …………………………………………….13 Oppositional defiant disorder (ODD) in ADHD ……………………. 15 Major depressive disorder (MDD) comorbidity in ADHD ………………………..17 Empathy …………………………………………………………………………………….18 Definition ……………………………………………………………………………….19 Empathy Development …………………………………………………………………20 Factors Affecting Empathy Development ……………………………………………...22 Gender differences in empathy ……………………………………...... 23 Genetics …………………………………………………………………………….24 Neural development ………………………………………………………………..24 Temperament ………………………………………………………………………25 Parenting …………………………………………………………………………..26 Parental Acceptance-Rejection ……………………………………………………………..27 Empathy in ADHD …………………………………………………………………………32 Empathy in ODD …………………………………………………………………………..37 Empathy in MDD …………………………………………………………………………...39 Summary of the Empathy Literature ………………………………………………………..42 Research Questions …………………………………………………………………………47

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CHAPTER 3: METHODOLOGY ………………………………………………………………48 Design ………………………………………………………………………………………49 Sample and Setting …………………………………………………………………………49 Inclusion/Exclusion Criteria ……………………………………………………………50 Sample Size …………………………………………………………………………….51 Variables and Measurement ……………………………………………………………….51 Diagnostic Groups …………………………………………………………………….51 Cognitive Empathy …………………………………………………………………….52 Emotional Empathy ……………………………………………………………………52 Mother and Father Acceptance-Rejection …………………………………………….53 Demographic and Clinical Data Sheet …………………………………………………55 Recruitment and Data Collection Procedures ………………………………………………55 Recruitment Procedures ……………………………………………………………….55 Data Collection Procedures …………………………………………………………….57 Ethical Considerations …………………………………………………………………58 Data Management and Analysis ……………………………………………………………59

CHAPTER 4: RESULTS ……………………………………………………………………….62 Demographic Characteristics …………………………………………………………..63 Clinical Characteristics ………………………………………………………………...64 Empathy and Parental Acceptance-Rejection …………………………………………66 Research Questions …………………………………………………………………………67 Research Question 1 …………………………………………………………………..68 Research Question 2 …………………………………………………………………..68 Post hoc testing…………………………………………………………………….69 Research Question 3 …………………………………………………………………..72 Research Question 4 …………………………………………………………………..73 Post hoc testing…………………………………………………………………...75 v

Research Question 5 …………………………………………………………………..77 Post hoc testing……………………………………………………………………78 Research Question 6 ……………………………………………………………………80 Post hoc testing…………………………………………………………………….81

CHAPTER 5: DISCUSSION ……………………………………………………………………84 Limitations ………………………………………………………………………………….93 Implications for Nursing Research and Practice ……………………………………………94

APPENDICES …………………………………………………………………………………….. A. Interpersonal Reactivity Index (IRI) Instrument ……………………………………….97 B. Mother Version of Parental Acceptance Rejection Questionnaire- Child Version (Short- Form) ………………………………………………………………………………….100 C. Father Version of Parental Acceptance Rejection Questionnaire- Child Version (Short- Form) …………………………………………………………………………………..103 D. Demographic and Clinical Data Sheet ………………………………………………...106 E. Clinical Data Sheet ……………………………………………………………………107

REFERENCES ………………………………………………………………………………108

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LIST OF TABLES

1. Subjects’ Demographic Characteristics …………………………………………………63

2. Subject’s Clinical Characteristics ……………………………………………………….65

3. Descriptive Characteristics of Cognitive and Emotional Empathy ……………………..66

4. Descriptive Statistics of Mother and Father Acceptance-Rejection …………………….67

5. Two-way ANOVA Summary for Gender, Diagnosis, and Cognitive Empathy ……….68

6. Two-way ANOVA Summary for Gender, Diagnosis, and Emotional Empathy ………..69

7. Descriptive Statistics for Emotional Empathy for Diagnostic Groups by Gender ……..69

8. Two-way ANOVA Summary for Gender, Diagnosis, and Emotional Concern ……….70

9. Descriptive Statistics of Emotional Concern for Diagnostic Groups by Gender ………..71

10. Two-way ANOVA Summary for Gender, Diagnosis, and Personal Distress …………..71

11. Descriptive Statistics of Personal Distress for Diagnostic Groups by Gender ………….72

12. Hierarchical Regression Analysis of Gender, Diagnosis, and Mother Acceptance-

Rejection on Cognitive Empathy ……………………………………………………….73

13. Hierarchical Regression Analysis of Gender, Diagnosis, and Father Acceptance-Rejection

on Cognitive Empathy …………………………………………………………………74

14. Hierarchical Regression Analysis of Gender, Diagnosis, and Father Acceptance-Rejection

on Fantasy ………………………………………………………………………………75

15. Hierarchical Regression Analysis of Gender, Diagnosis, and Father Acceptance-Rejection

on Perspective Taking ………………………………………………………………….76

16. Hierarchical Regression Analysis of Gender, Diagnosis, and Mother Acceptance-

Rejection on Emotional Empathy ………………………………………………………77

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17. Hierarchical Regression Analysis of Gender, Diagnosis, and Mother Acceptance-

Rejection on Emotional Concern ………………………………………………………78

18. Hierarchical Regression Analysis of Gender, Diagnosis, and Mother Acceptance-

Rejection on Personal Distress …………………………………………………………79

19. Hierarchical Regression Analysis of Gender, Diagnosis, and Father Acceptance-Rejection

on Emotional Empathy …………………………………………………………………80

20. Hierarchical Regression Analysis of Gender, Diagnosis, and Father Acceptance-Rejection

on Emotional Concern …………………………………………………………………81

21. Hierarchical Regression Analysis of Gender, Diagnosis, and Father Acceptance-Rejection

on Personal Distress …………………………………………………………………….82

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SHAHROUR, GHADA, Ph.D., December 2017 Nursing

COGNITIVE AND EMOTIONAL EMPATHY IN ADOLESCENTS WITH ADHD: ARE COMORBIDITIES, GENDER, AND PARENTAL ACCEPTANCE-REJECTION IMPORTANT FACTORS? Director of Dissertation: Wendy Umberger

Abstract

Empathy is considered an important aspect of effective social communication. Adolescents with ADHD experience difficulties in several social domains including peer, sibling, and parent- child relationship. Social difficulties are intensified when ADHD diagnosis is accompanied with comorbidities such as oppositional defiant disorder (ODD) and major depressive disorder

(MDD). To date, empathy in ADHD has been studied in of those comorbidities although they have been reported to be common among adolescents with ADHD. Furthermore, findings of empathy literature on these diagnoses were mixed and inconclusive. Gender and parenting empathic responses and literature is lacking on the role of these variables on empathy in ADHD. Therefore, this study investigated the role of ODD and MDD comorbidities, gender, and parental acceptance-rejection on cognitive (CE) and emotional empathy (EE) among adolescents with ADHD.

This study used a comparative design. The sample was recruited from two mental-health outpatient settings in Northeast Ohio. One hundred and three adolescents with the diagnosis of

ADHD-C, ADHD-C and ODD, and ADHD-C and MDD were recruited. The age of the sample ranged from 12 to 18 years old and subjects were mainly Caucasian. Adolescents completed two measures; the Interpersonal Reactivity Index (Davis, 1983) that assess CE and EE, and mother

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and father versions of the Parental Acceptance-Rejection Questionnaire-Child Version (Short-

Form). Perspective taking and fantasy subscales of IRI measured CE, while emotional concern and personal distress assessed EE. Demographic data and clinical information were obtained as well. Two-way ANOVA was used to determine the effect of gender and diagnosis on CE and

EE. Hierarchical multiple regression was conducted to test the moderating effect of parental acceptance-rejection on CE and EE.

The findings showed no differences in CE according to gender and diagnoses (i.e., ADHD-C,

ADHD-C and ODD, ADHD-C and MDD). Regarding EE, females scored higher than males on both subscales of EE; emotional concern, and personal distress. Adolescents with ADHD-C and

ODD comorbidity scored significantly lower than the other two groups on both measures of EE.

Females with ADHD-C and ODD had the lowest EE, specifically they had the lowest scores on emotional concern subscale. Parental acceptance-rejection moderated the relationship between

ADHD-C and MDD diagnosis and both CE and EE. Paternal rejection resulted in lower fantasy scores among subjects with ADHD-C and MDD, while maternal rejection yielded lower emotional concern.

Findings from this study showed that comorbidity of ODD in adolescents with ADHD-C intensified empathic difficulties, particularly EE. Parental rejection played a role in empathic responses for subjects with ADHD-C and MDD comorbidity. professionals may incorporate this knowledge when providing care to adolescents with ADHD. Designing and implementing interventions to improve empathic responses in this population is warranted as well. Future research is needed to further investigate empathy, its possible etiologies, and the

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mechanisms of the effect of possible parenting components on empathy in individuals with

ADHD and ADHD with common comorbidities.

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Chapter 1

INTRODUCTION

1 Background and Significance

Attention Deficit Hyperactivity Disorder (ADHD) is on the rise (Health, 2011). In the

U.S., more than 1 in 10 school-age children are diagnosed with ADHD, representing approximately 11% of children aged 4 to 17 years old (Center for Disease and Prevention

Control [CDC], 2017). There has been roughly a 29% increase in ADHD diagnosis from 2003 to

2011 (CDC, 2017). ADHD symptoms are characterized by inattention, hyperactivity and (American Psychiatric Association [APA], 2013). According to the Diagnostic and

Statistical Manual of Mental Disorders, 5th edition (DSM-5), ADHD is classified into three categories: (a) inattentive type (ADHD-I); (b) hyperactive and impulsive type (ADHD-H), and;

(c) ADHD-combined type (ADHD-C) where typical symptoms of impulsivity, inattention, and hyperactivity are all present at once. Symptoms of ADHD can occur before age of 12. For adults and adolescents of age 17 and older, only five symptoms are required for diagnosis instead of the six needed for younger children (APA, 2013).

Existing literature documents high rates of comorbid externalizing and internalizing disorders in children and adolescents with ADHD. are those disorders in which distress is expressed outwards; common externalizing disorders include oppositional defiant disorder (ODD) and conduct disorder (Gosgrove et al., 2011). Most common internalizing disorders are major depressive disorder, , and disorders in which individuals with these disorders have the propensity to express distress inwards (Gosgrove et al.,

2011). The most prevalent externalizing and internalizing disorders in adolescent with ADHD include: oppositional defiant disorder (ODD), conduct disorder (CD), major depressive disorder

(MDD), and (Connor et al., 2003; Faraone, Biederman, & Monuteaux, 2002;

Jensen et al., 2001; Lee, Humphreys, Flory, Liu, & Glass, 2011; Wells et al., 2006). The severity

2 of ADHD symptoms is positively correlated with the occurrence of comorbid disorders and these comorbidities are more frequent in ADHD-C (Burns & Walsh, 2002; Connor et al., 2003;

Hinshaw, 2002). The development and trajectories of comorbid disorders in the ADHD population are associated with age. While externalizing problems of ODD and CD develop at earlier age and continue through , MDD and anxious symptoms have a later age of onset (i.e., during early adolescence) (Connor et al., 2003; Jerrell, McIntyre, & Park, 2015).

Two of the most frequent comorbid disorders in adolescents with ADHD are ODD and

MDD. Estimates of ODD in adolescents with ADHD range from 58% to 75% (Barkley,

Edwards, Laneri, Fletcher, & Metevia, 2001; Yang, Shang, & Gau, 2011), while MDD can be found at rates of 24% to 30% (Blackman, Ostrander, & Herman, 2005). Although ODD is more common in ADHD boys than ADHD girls in childhood years, recent work suggests that this difference disappears by adolescence and the incidence becomes equal between both genders

(Biederman et al., 2006).

Adolescents with ADHD experience difficulties in several social domains including peer, sibling, and parent-child relationships. These adolescents can have negative parent-child and sibling interaction (Loe & Feldman, 2007). They also tend to have fewer close friendships, greater peer rejection, and persistent aggressive interpersonal behavior (Bagwell, Molina,

Pelham, & Hoza, 2001; Glass, Flory, & Hankin, 2010). As a result of such social impairments, adolescents with ADHD are often characterized as loners who experience difficulties in maintaining friendships, which leads to low self-esteem (Barkley, 2000; Hoza, 2007; Nijmeijer et al., 2008). Interestingly, findings show that children and adolescents diagnosed with ADHD-C experience more severe social difficulties than those with ADHD-I type (Barkley, 2006;

Maedgen & Carlson, 2000; Semrud-Clikeman, 2010).

3 Comorbid disorders of ODD and MDD are found to intensify the social difficulties experienced by adolescents with ADHD. For example, findings from some studies demonstrate that the comorbid conditions of ADHD and ODD increases peer problems more than the presence of ADHD or ODD alone. Specifically, adolescents with ADHD and ODD were less accepted by peers than children with either ADHD or ODD (Bagwell et al., 2001; Harpin, 2005).

Similar findings were reported in ADHD adolescents with comorbid MDD (Blackman et al.,

2005)

One important aspect of effective social communication and interaction is the ability to empathize. Empathy refers to the individual’s ability to understand and engage in another’s emotional state (Smith, 2006; Spreng, McKinnon, Mar & Levine, 2009). There is a consensus in the literature that empathy is composed of two components, cognitive and emotional. Cognitive empathy refers to the ability of taking the perspective of others and understanding their emotional state; while the emotional component deals with the emotional response that is congruent with the other’s emotional state (Decety & Jackson, 2004; Smith, 2006). Empathy is a crucial element in the development of social relations, inhibition, improvement of bonding between the child and the parent, and development of friendship. It also facilitates conversation and social expertise through understanding and predicting the behaviors of others

(Ellis & Zarbatany, 2007; Hoffman, 1987; Plutchik, 1987; Schrandt, Townsend, & Poulson,

2009). Difficulties related to the ability to empathize often have some serious repercussions for adolescents including interpersonal difficulties (Ellis & Zarbatany, 2007), academic underachievement (Caprara, Barbaranelli, Pastorelli, Bandura, & Zimbardo, 2000; Miles &

Stipek, 2006), delinquency, and drug use (Fothergill & Ensminger, 2006; Pursell, Laursen,

Rubin, Booth-LaForce, & RoseKrasnor, 2008).

4 Similar to the social impairments experienced by adolescents with ADHD, particularly

ADHD-C type, empathetic difficulties are also reported, although the nature of the empathetic impairment is not agreed upon. Furthermore, there has been no investigation about whether empathetic profiles differ between adolescents with ADHD and those with ADHD with comorbidities, specifically ODD and MDD, even though social difficulties are reported to be more severe when ADHD coexists with ODD and MDD (Bagwell et al., 2001; Blackman et al.,

2005; Harpin, 2005; Keller, Lavori, Beardslee, Wunder, & Ryan, 1991; Kuhne et al., 1997).

Furthermore, findings in some studies show that there is a significant number of adolescents with

ADHD that also are diagnosed with ODD (e.g., Clark, Feehan, Tinline & Vostanis, 1999); therefore, inferences as to whether empathy impairments are related to the ADHD diagnosis itself or to the accompanying comorbidity are unclear in this population.

Empathy has been studied separately in ADHD, ODD, and MDD; however, findings show inconsistences on the nature of empathetic impairment (i.e., cognitive versus emotional or both). Furthermore, studies of empathy in subjects with MDD included only adults, while those with subjects diagnosed with ODD included heterogeneous samples of children and adolescents.

Studies of empathy in ODD population included subjects with conduct disorder as well and combined both disorders under one term, disruptive behavior disorders (DBD). Therefore, understanding empathetic abilities and/or deficits for a specific developmental age such as adolescence or distinct disorder is inconclusive.

The development of empathy is influenced by several factors, which can be genetic or environmental (Zahn-Waxler, Radke-Yarrow, Wagner, & Chapman, 1992). One aspect of environmental influences on empathy is parenting (Feldman, 2007). Parental acceptance or rejection has been studied in relation to empathy development, specifically emotional empathy. It

5 has been reported that emotional empathy is facilitated in families where parents exhibit warmth, nurturance and overall acceptance of the child, and inhibited when parents are perceived to be rejecting of their children (Arzeen, Hassan, & Riaz, 2012; Kim & Rohner, 2003). Although parental acceptance or rejection has been studied in relation to empathy in typical adolescents, to date there has been no research exploring the effect of this construct in regard to empathy in adolescents with ADHD and those with ADHD with comorbidities of ODD or MDD.

Empathic differences according to gender have been reported in the literature, although findings are inconsistent. Some studies concluded with women being more empathic than men cognitively and emotionally (e.g., Baron-Cohen & Wheelwright, 2004; Davis, 1983; Eisenberg

& Lennon, 1983; Rueckert & Naybar, 2008), while others found no differences (Lamm et al.,

2011; Singer et al., 2004). Other studies reported women having more emotional empathy than men (Derntl et al., 2010; Mestre, Samper, Frias, & Tru, 2009; Rueckert, Branch, & Doan,

2011).Research findings give strong support for adolescent females are having more empathy than adolescent males (Auyeung et al., 2009; Mestre et al., 2009). In studies of empathy in

ADHD, the majority failed to consider gender differences. Only a very few reported that girls with ADHD had higher scores of empathy than boys on measures of both cognitive and emotional empathy (Clark et al., 1999; Gambin & Sharp, 2016; Marton, Wiener, Rogers, Moore,

& Tamnock, 2009). The literature related to empathy in ODD and MDD population failed to assess gender differences and the majority of empathy studies in the ODD population included only boys.

The specific aims of this study are to: a) determine whether differences in cognitive empathy exist based on gender and diagnosis (i.e., ADHD-C, ADHD-C with ODD, and ADHD-

C with MDD) b) determine whether differences in emotional empathy exist based on gender and

6 diagnosis (i.e., ADHD-C, ADHD-C with ODD, and ADHD-C with MDD); and c) determine the role of parental acceptance-rejection on empathetic responses in adolescents with ADHD-C,

ADHD-C with ODD and ADHD-C with MDD.

Theoretical Framework

The theoretical framework that will be used in this study is the Empathy Imbalance

Hypothesis (Smith, 2009). This theory proposes different combinations of cognitive (CE) and emotional empathy (EE); CE and EE can be separate or complementary (i.e., one can exist without the other or they can be integrated) (Smith, 2006). More specifically, this theory proposes that humans can use CE without EE, to use EE without or before CE, or to use CE and

EE together (Smith, 2006). For instance, deceiving requires the use of CE while the EE is inhibited, parental response to their distressed children can be stimulated by the use of EE that precedes CE, while general prosocial behaviors such as comforting requires balanced empathy where CE and EE are integrated. Because these two components of empathy can exist separately, each can balance, influence, and regulate the other while retaining some degree of independence.

Smith (2009) hypothesized the existence of four empathetic disorders: (a) CE deficit disorder where low CE ability is combined with high EE sensitivity; (b) EE deficit disorder where low EE sensitivity is combined with high CE ability; (c) general empathy deficit disorder in which there is low CE ability and low EE sensitivity; and (d) general empathy excess disorder where both CE ability and EE sensitivity are high.

This theory has been widely used to understand several specific psychiatric disorders, particularly, spectrum disorder (ASD), antisocial personality disorder, and conduct disorder. For example, autism and antisocial personality disorder are opposite empathy imbalance disorders; ASD is an example of the first classification (i.e., CE deficit disorder) and

7 antisocial personality disorder represents the second category (i.e., EE deficit disorder). In the case of CE deficit, Smith (2009) suggests that the lack of cognitive empathy makes it difficult for individuals to channel their empathetic concerns in a flexible way. He further adds that these individuals would spontaneously develop ways of limiting the they pay to others’ , especially if the emotions that have been expressed are negative. Individuals, such as those with ASD, will exhibit avoidance and stereotyped behaviors, or insist on routines when they are over-aroused by negative . Such responses will reduce their personal distress as they lack CE to regulate their EE response. On the other hand, Smith (2009) proposes that people with CE deficit disorder may enjoy the company of happy people who behave in a predictable and consistent way.

The Empathy Imbalance Hypothesis will be used to predict the empathetic responses for adolescents with ADHD-C and its comorbidities, ADHD-C with ODD, and ADHD-C with

MDD. Findings in empathy studies in the ADHD literature report that adolescents with ADHD have difficulties matching their emotions with those of the protagonist when the story elicited negative feelings. These findings didn’t hold true for stories that evoked happy feelings, indicating that positive feelings are easier for those with ADHD to match and identify with

(Braaten & Rosen, 2000; Pelc, Kornreich, Foisy, & Dan, 2006). The lack of CE in ADHD individuals, as reported in several studies, may explain the difficulties of these individuals to empathize with others emotionally, which is similar to empathetic deficits in individuals diagnosed with ASD. Similar empathetic responses were reported in children and adolescents with ODD who responded congruently with stories of happy feelings but not negative ones (de

Wied, Boxtel, Posthumus, Goudena, & Matthys, 2009; de Wied, Boxtel, Zaalberg, Goudena, &

Matthys, 2006, de Wied, Goudena, & Matthys, 2005).

8 Although findings in the majority of studies with individuals diagnosed with MDD show high personal distress when subjects empathized with others (Derntl et al., 2012; O'Connor,

Berry, Weiss, & Gilbert, 2002; Schneider et al., 2012; et al., 2011; Wilbertz, Brakemeier, Zobel,

Harter, & Schramm, 2010) and their cognitive empathy was lacking (e.g., Cusi, Macqueen,

Spreng, & McKinnon, 2011; Donges et al., 2005), it has been difficult to classify their empathetic reactions according to this theory’s classification system described above. This is because there are inconsistences in research findings, which questions whether cognitive empathy in this population is actually impaired (Derntl et al., 2012; O'Connor et al., 2002;

Schneider et al., 2012; Thoma et al., 2011; Wilbertz et al., 2010) or not. (e.g., Schneider et al.,

2012; Thoma et al., 2011; Wilbertz et al., 2010).

Most importantly, the Empathy Imbalance Hypothesis provides a model for assessment and prediction of empathetic responses based on the interaction of ODD and MDD comorbidities with ADHD-C diagnosis. Furthermore, since this study will differentiate individuals with pure

ADHD-C from other comorbidities, categorizing each of the three disorders (ADHD-C, ADHD-

C with ODD, and ADHD-C with MDD) according to this theory’s classification will provide a practical value for designing interventions that target each disorder’s specific empathy impairment(s).

Significance to Nursing

Nurses are essential health care providers for patients diagnosed with ADHD who present in a variety of healthcare settings including primary care, school, and in-patient and outpatient mental health facilities. ADHD is on the rise (CDC, 2017) and the unmet needs of this population, especially specialty and therapy care needs, are growing (Steer, 2005).

Unfortunately, there is a lack of sufficient research and consistent evidence to guide nurses and

9 other health professionals to have deeper understanding of the behavioral and emotional difficulties facing children diagnosed with ADHD. Empathy is considered a vital process for individuals’ psychological and social well-being and the ramifications of deficits in empathy are tremendous (e.g., Hay, Hudson, & Liang, 2010; Hoza, Mrug, Pelham, Greiner, & Gnagy, 2003;

Ollendick et al., 1992).

Gaining insight into the nature of empathetic reactions or deficits that are specific to individuals with ADHD and differentiate them from those related to comorbidities often associated with ADHD, can result in beneficial outcomes to the child, parents, and healthcare professionals who work with them. Such outcomes include: (a) increased knowledge about empathy in children diagnosed with ADHD and ADHD with comorbidities and the role of parenting and gender; (b) evidence-based interventions that are tailored to the specific disorder to improve empathy in children with ADHD with and without comorbidities; and (c) evidence- based interventions to impart information to parents about the empathetic reactions and deficits of their child-specific disorder and ways to respond effectively to their child’s empathetic responses. The latter may be helpful in reducing stress commonly experienced by parents with children diagnosed with ADHD. Often times, parents and families of children with ADHD experience stress, anxiety, and MDD due to the uncertainty of their children’s symptoms and how to effectively cope with them (Baker, 1994; Kashdan et al., 2004; Harrison & Sofronoff,

2002). Understanding the role of parental acceptance or rejection on empathy among adolescents with ADHD is an important target for nursing interventions as well. Such interventions may aim at providing parents with the necessary education on the role parenting play to improve empathic abilities of their adolescents. Another avenue is through implementing interventions to improve child-parent relationship which can be a target for family therapy.

10 Nurse scientists can take a leading role in investigating and effectively designing interventions to treat children and adolescents with ADHD, which is identified as a national research priority (CDC, 2014). Designing evidence-based interventions related to improving empathy will enable nurses and other health professionals to utilize these interventions with patients diagnosed with ADHD. The increased shortage of child and adolescent mental health professionals, accompanied by the increased need for services for children and adolescents diagnosed with ADHD (Melnyk, 2007), calls attention to the need for research on processes characteristic of these disorders, along with the evidence-based interventions. The knowledge that will be generated from this research study will help nurses to understand the nature of the empathetic deficits and abilities in the ADHD population and whether these deficits vary with gender, the presence of ADHD comorbidities, and parental acceptance or rejection. Such understanding will provide an avenue for designing and implementing tailored and innovative nursing interventions to improve the quality of life for the individuals diagnosed with the disorders and their families.

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Chapter 2

REVIEW OF THE LITERATURE

12 Background on ADHD

Attention Deficit Hyperactivity Disorder (ADHD) is characterized by three main core symptoms: hyperactivity, inattention, and impulsivity. Until recently, ADHD was considered a childhood disorder. It has now been found to persist through adulthood. Findings from studies report that approximately 4% to 15% of childhood onset ADHD persists into adulthood

(Faraone, Biederman, & Mick, 2006; Kessler et al., 2006). Similar to the DSM-IV-TR diagnostic criteria for ADHD, the DSM-V criteria are divided into two categories: inattention, and hyperactivity and impulsivity. Characteristic behaviors of individuals with ADHD include: fidgeting, failure to pay attention, difficulty organizing tasks and activities, excessive talking, and inability to remain seated in appropriate situations (American Psychiatric Association

[APA], 2013). According to the DSM-V, the onset of ADHD symptoms must be present before a person reaches 12 years of age (APA, 2013). The functional limitations related to ADHD commonly result in academic, peer, and family problems (APA, 2013; Loe & Feldman, 2007;

Nijmeijer et al., 2008). In addition, children and adolescents with ADHD are likely to have higher rates of unintentional injuries, emergency department visits, smoking, alcohol consumption, and illicit substance use (Charach, Yeung, Climans, & Lillie, 2011).

Prevalence, Etiology, and Comorbidities

The prevalence of ADHD in children aged 4 to 17 years is estimated to be 11%, representing 6.4 million children (CDC, 2017). The diagnosis of ADHD has increased from

7.8% in 2003 to 11% in 2011 and it is the most prevalent childhood diagnosis among children aged 3 to 7 years old as reported by parents (6.8%) (CDC, 2017). A substantial body of research strongly suggests a genetic vulnerability to ADHD, with several genes involved in the dopaminergic and the serotonergic systems that are implicated (Faraone et al., 2005; Mick &

13 Faraone, 2008; Thapar, Langley, Owen, & O’Donovan, 2007) and that these genetic underpinnings are complex (Mick & Faraone, 2008). Other predictors of ADHD may include prenatal maternal smoking, low birth weight, and other prenatal problems, such as antepartum hemorrhage and length of labor (Connor, 2002; Chandola, Robling, Peters, Melville-Thomas, &

McGuffin, 1992; Wilens et al., 2008). The effect of food preservatives and artificial food coloring as predicting factors of ADHD have been controversial. Findings in several studies show that food preservatives and artificial food coloring increase hyperactivity in children already diagnosed with ADHD and the elimination of these elements result in lower hyperactivity (Boris, & Mandel, 1994; Schab & Trinth, 2004); however, earlier studies did not support these relationships (Goyette , Connors , Petti, & Curtis, 1978;

Gross, Tofanelli, Butzirus, & Snodgrass., 1987). Environmental factors in the context of familial contributions to the development to ADHD symptoms were not found; however, ADHD symptoms were found to affect the child-family relationships. Families with a child with ADHD were found to have more stress, and family members experienced anxiety and

(Podolski & Nigg, 2010). Disturbances in family functioning and conflicted parent-child relationship were also reported (Deault, 2010; Johnston & Mash, 2001).

Comorbidities of ADHD are well-established in the literature. Findings in several studies show that individuals with ADHD tend to have comorbid conduct, oppositional defiant disorders and internalizing disorders (Faraone et al., 2002; Wells et al., 2006). Among adolescents with

ADHD, academic underachievement and school failure, problematic social relations, risk for antisocial behavior patterns, teen pregnancy, and adverse driving consequences have been identified as potentially serious problems (Barbaresi, Katusic, Colligan, Weaver, & Jacobsen,

2007; Hinshaw, 2002; Mrug et al., 2009 ). Comorbidities of ADHD may persist into adulthood,

14 although many adults with ADHD learn how to better cope with this disorder (Barkley, Fischer,

Fletcher, & Smallish, 2002; Turgay et al., 2012). Nevertheless, ADHD in adults can be associated with antisocial, mood and anxiety disorders, and (Biederman, 2004).

Persistence of ADHD and comorbid conditions into adulthood add to economic burden, the extent of which is currently unknown (Biederman, 2004).

Oppositional defiant disorder (ODD) comorbidity in ADHD. ODD is considered one of the most frequent comorbidities that occurs in children and adolescents with ADHD (Barkley,

2011). This disorder is characterized by a pattern of defiant, hostile, and negativistic behavior, such as arguing with others, refusing to comply with adults’ rules and requests, losing temper frequently, and being angry and vindictive. These behaviors cause significant impairment in social or academic settings (APA, 2013).

Several studies report the prevalence of ODD in subjects with ADHD diagnosis. The prevalence rate varies according to the age of the subjects in the sample, with increased prevalence of ODD comorbidity in adolescence (Nock et al., 2007). For example, in school-age children with ADHD, the occurrence of ODD was reported to be 28% (Keenan & Wakschlag,

2004), while adolescents with ADHD were reported to have as high as 58% to 75% of ODD comorbidity (Barkley et al., 2011; Yang et al., 2011). Although ODD is more common in males with ADHD than in females during childhood years, recent research suggests that this difference disappears by adolescence and becomes equal between both genders (Biederman et al., 2006).

Interestingly, the prevalence of ODD also varies according to the subtype of ADHD diagnosis. A substantial higher prevalence rate of ODD was found in subjects diagnosed with the combined type (ADHD-C) than those with inattentive type (DHD-I) (Burns & Walsh, 2002;

Hinshaw, 2002; Lalonde, Turgay, & Hudson, 1998). Hinshaw (2002) found that children

15 diagnosed with AHDH-C were two times more likely to have comorbid ODD. Interestingly,

Burns and Walsh (2002) found that symptoms of ADHD-C predicted ODD comorbidity, but not those of ADHD-I.

The combined effect of the symptoms of ADHD and ODD has a negative impact on the adolescents’ social, academic, and family functioning. While families of children with ADHD experience high levels of stress, depression, and paternal , research findings indicate a higher rate of these problems in parents of children with comorbid ADHD and ODD than those with children diagnosed solely with ADHD alone (Kashdan et al., 2004; Kilic &

Sener, 2005; Pfiffner, McBurnett, Rathouz, & Judic, 2005). Families of adolescents with combined ADHD and ODD were also found to have higher levels of conflict, less positive parenting, significant distress, and higher rates of anxiety and MDD than in families with adolescents who have ADHD only (Kashdan et al., 2004; Pfiffner at al., 2005). On the academic level, ODD comorbidity was found to worsen school performance and increase classroom behavioral problems (Liu, Huang, Kao, & Gau, 2017; Drabick, Gadow, Carlson, & Bromet,

2004). Adolescents with ADHD and ODD comorbidity had more negative attitude toward schoolwork, disturbed social interaction, and more behavioral problems than youth with ADHD only (Liu et al., 2017). These problems are more severe and profound in children with ADHD-C and comorbid ODD; these children are more likely to receive disciplinary referrals and negative comments from teachers in their school records (Gresham, MacMillan, Bocian, Ward, &

Forness, 1998; Liu et al., 2017).

Social difficulties were also reported to be more severe in adolescents with combined

ADHD and ODD than in adolescents with ADHD alone. These adolescents reported severe lack of friendship and their interactions with their peers were hostile, intrusive, commanding, and

16 impulsive (Harpin, 2005). Therefore, adolescents with ADHD and ODD report a higher rate of peer rejection than those with ADHD alone (Bagwell et al., 2001). Finally, adolescents with

ADHD and ODD are more likely to be bullied and to become bullies themselves (Wehmeier,

Schacht, & Barkley, 2010).

Major Depressive Disorder (MDD) comorbidity in ADHD. MDD is another frequent comorbid disorder in ADHD; it occurs in 6% to 8% of adolescents in the general population

(Costello, Copeland, & Angold, 2011) and the prevalence in adolescents with ADHD is found to be higher; 24% to 30% (Barkley, 2006; Chronis-Tuscano et al., 2010). In a review of studies of community samples, rates of MDD in youth with ADHD ranged from 12% to 50% (Angold et al., 1999). The onset of MDD in subjects with ADHD is typically several years after the diagnosis of ADHD. Jerrell et al., (2015) found that 5.6% of subjects diagnosed with ADHD at mean age of 7 years had a diagnosis of MDD at age 12. Children and adolescents with ADHD were more likely to develop MDD (14%) than those without ADHD (1%) (Larson, Russ, Kahn,

& Halfon, 2011).

Several factors have been suggested to contribute to the increased rate of MDD in adolescents with ADHD despite the artifact of rater bias, overlapping symptoms, or methodological shortcomings (Daviss, 2008). Early symptoms of ADHD lead to impairments in social relationships, academic functioning, and parental interactions which may directly or indirectly contribute to MDD development (Ostrander, Crystal, & August, 2006; Ostrander &

Herman 2006; Herman, Lambert, Ialongo, & Ostrander, 2007). Negative environmental conditions, such as poor interpersonal relationships with family members or peers and child maltreatment are other contributing factors (Daviss, Diler, & Birmaher, 2009; Daviss, 2008).

ADHD- related treatment, especially with psycho-stimulants, and the presence of physical

17 illness, such as obesity, diabetes mellitus, thyroid disorders, or epilepsies, can also be associated with MDD in some patients (Blackman et al., 2005; de Zwaan et al., 2011). Other comorbidities, such as the anxiety, ODD, and conduct disorder (CD), may increase the risk for the development of MDD in children and adolescents with ADHD (Daviss, 2008; Jerrell et al., 2015; Spencer,

Biederman & Mick, 2007). Blackman et al. (2005) reported higher prevalence of MDD in youth with ADHD without comorbidities than with those without ADHD.

Adolescents with ADHD and MDD display greater levels of psychological impairments than youths with either ADHD or MDD alone. These youths have earlier onset and longer durations of depressive episodes, are at risk for higher rates of suicidality, frequent hospitalization (Biederman et al., 2008), depression recurrence (Rohde, Clarke, Lewinsohn,

Seeley, & Kaufman, 2001) and higher overall health care costs (Fishman, Stang, & Hogue,

2007). Research findings report that persistence of MDD in adolescents with ADHD is related to social problems and academic difficulties, independent of externalizing behaviors, such as ODD or CD (Herman et al., 2007; Ostrander et al., 2006). MDD comorbidity in individuals with

ADHD was found to intensify social difficulties as well. Blackman et al. (2005) reported that children with comorbid ADHD and MDD had more severe social problems than children with

ADHD only including poorer social skills and lower school popularity and friendship. These higher dysfunctions were not related to externalizing behaviors or the differences in ADHD symptoms’ severity between both groups (Blackman et al., 2005). These findings were congruent with a recent study in which comorbid MDD was significantly associated with poorer parent- reported social functioning in adolescents with ADHD than those with ADHD diagnosis (Becker et al., 2015).

Empathy

18 Definition

The term empathy is a translation of a German word which means “ into” (Wispe,

1987). Empathy refers to one’s ability to understand the emotional state of others and respond adaptively to such states (Spreng et al., 2009). Decety and Jackson (2004) describe empathy as a natural-occurring subjective phenomenon, which is an inborn characteristic and hardwired in the brain. Its development occurs through interaction with others; without such interaction and development of emotional bonds, empathy is unlikely to develop (Decety & Jackson, 2004).

There has been an ample amount of work to understand what constitutes empathy and to differentiate it from other concepts, such as and perspective taking. Some experts view empathy as sharing of both positive and negative emotions, which leads to increased probability of eliciting similar behaviors between individuals (Smith, 2009). Others question whether empathy is a voluntary response or not. For Hoffman (1987), empathy is largely an involuntary vicarious response to emotional cues from another person, whereas Davis (1996) stresses the conscious role-taking ability, which taps mainly into cognitive resources. Still other researchers argue that intentionally of empathy should occur when the person feels for and act on behalf of others whose experience is largely different than their own (Batson, 1991; Decety & Hodges,

2004).

Recently, efforts have been focused on elucidating whether empathy involves an emotional versus a cognitive process or a combination of both. Emotional empathy (EE) is commonly thought of as an emotional reaction (e.g., ) to another’s emotional response (e.g., ). This reaction is not dependent on a cognitive understanding of why a person is feeling a certain way (Ranklin, Kramer, & Miller, 2005), although it may facilitate understanding and action. By contrast, cognitive empathy (CE) involves an intellectual or

19 imaginative apprehension of another’s emotional state, often described as overlapping with the construct of theory of mind (i.e., understanding the thoughts and feelings of others) and used interchangeably by some authors (Lawrence, Shaw, Baker, Baron-Cohen, & David, 2004).

Early researchers viewed empathy as an emotional state only. For example, Hoffman

(1987) identified empathy as an emotional response to someone’s situation. Eisenberg and

Strayer (1987) also regarded empathy as an emotional response that stems from another’s emotional state; the emotional response is congruent with other’s condition and emotional state.

On the other hand, Hogan (1969) referred to empathy as the ability to construct another person’s mental state in one’s mind (i.e., CE). Cognitive abilities such as observation, knowledge, memory, reasoning, awareness of self and others, as well as the ability to regulate one’s emotions, are thought to be necessary to yield insights to other’s feelings and thoughts in addition to the emotional responses of empathy, (Decety & Jackson, 2004).

Currently, there is a broad agreement in the literature that empathy has two main components, emotional, which requires the ability to share the emotional experience of others, and cognitive, which is the ability to understand such an experience. For example, according to

Baron-Cohen (2002), empathizing is “the drive to identify another person’s emotions and thoughts and to respond to these with an appropriate ” (p. 248). This definition presents

CE as the first step in empathizing and EE as the second step. Recent literature emphasized the need for both emotional and cognitive components of empathy to understand and distinguish empathetic reactions for different psychiatric disorders (Smith, 2006).

Empathy Development

Early theorists suggested that young children are too egocentric, or otherwise not cognitively able to experience empathy (Freud, 1958; Piaget, 1965). However, later studies

20 provided evidence on the ability of young children to display a variety of sophisticated empathy- related behaviors. Furthermore, precursors to empathy were suggested to occur as early as 18 to

72 hours following birth. Newborns were found to respond more strongly to another’s infant cry than to a variety of stimuli, including non-human cry sounds, silence, synthetic cry sounds, and their own cries. Such responses are labeled as reflexive crying, or reactive crying (Zahn-Waxler

Radke-Yarrow, & King, 1979; Zahn-Waxler et al., 1992). This suggests that newborns’ reactive crying to another newborn was not simply a reaction to the aversive noise of the cry, but an early precursor to empathetic responding. Such reaction also supports the idea that empathy has a biological predisposition, since the newborns showed and responsiveness to the negative feelings of others.

Developmentally, infants are unable to differentiate the self from others, but are thought to have basic emotion regulation capacities. A precursor to empathy responding was suggested to occur in infants when they were observed displaying distress in response to other’s negative emotional experiences and lead to engagement in self-comforting behaviors to reduce their distress (Hoffman, 1975; Zahn-Waxler & Radke-Yarrow, 1990). By the second and third years of life, toddlers have the capacity to differentiate the self from others and can engage in several empathy-related behaviors, including showing concern and prosocial behavior. Toddlers at 2 years of age are capable of displaying prosocial behaviors, such as giving advice and verbal comfort, sharing, and distracting the person in distress, whether that person is a parent or a total stranger to the toddler. By the third year of life, toddlers are able to express verbal and facial concern (e.g., “I’m sorry” and sad facial expression), to show interest in others’ distress (e.g.,

“What happened?”) and continue to engage in prosocial behaviors. These forms of empathy

21 related-behaviors from newborn to toddlerhood are mainly indicative of EE (Knafo, Zahn-

Waxler, Van Hulle, Robinson, & Rhee, 2008; Zahn-Waxler et al., 1992).

By preschool age (i.e., 4 to 5 years of age), there are significant gains, particularly in the area of CE. Children are now able to take the perspective of others due to their increased verbal and language capacities. The false belief task is a test for the development of CE in this age group (Wellman, Cross, & Watson, 2001). In this task, the child is presented with a scenario of two characters in which one of the characters places an item in a given location and leaves the room. Then, the second character enters the room and moves the item to a new location. When the first character enters the room, the child is asked where the first character will look for the item. If the child has CE, the response will be the original location, thus indicating the capacity to view the situation from the perspective of the character that left the room (Wellman et al.,

2001).

Despite little evidence, it is suggested that empathetic abilities stabilize and become consistent in adulthood once they are developed during childhood. Eisenberg, Guthrie, Murphy,

Shepard, and Cumberland (1999) found that early prosocial behaviors predicted later prosocial predisposition in a sample of children followed longitudinally from age 4 to 20 years; this relationship was mediated by empathy-related responding. In the study of Knafo et al. (2008), empathy was suggested to be a relatively stable disposition across its emotional and cognitive components and across ages as well.

Factors Affecting Empathy Development

Several factors were found to contribute to the development of empathy. Within-child factors include: gender, genetic makeup, neural development, and temperament. Environmental factors include: parenting and parent-child relationship

22 Gender differences in empathy. There is a long-standing belief, especially among the lay public, that women are more empathetic than men; however, findings in the scientific literature are mixed. Women are found to be more empathetic in studies that assessed empathy using self-report measures (e.g., Baron-Cohen & Wheelwright, 2004; Davis, 1983; Eisenberg &

Lennon, 1983; Rueckert & Naybar, 2008). Women were reported as being more empathetic than men on CE and EE; however, some studies found that the gender differences tend to be greater for women on the scales for EE only (Derntl et al., 2010; Mestre et al., 2009; Rueckert et al.,

2011). Since self-report measures are subjective in nature, gender differences might be attributed to external factors, such as demand characteristics in which women believe they are expected to exhibit empathy (i.e., social desirability), and therefore exhibit greater empathy when it is obvious that this is what is being tested (Rueckert et al., 2011).

In the majority of physiologic studies that utilized more objective measures of empathy

(e.g., measurement of brain activity), gender differences were non-existent (Lamm et al., 2011;

Singer et al., 2004). In a few studies where women had lower scores of empathy than men, a stereotype threat (i.e., women were told they are not expected to perform better than men) was a possible explanation for women scoring lower than men on empathy measures. The absence of significant gender differences in some of the physiologic studies may relate to low power due to small sample sizes (Rueckert et al., 2011), making it difficult to conclude whether there were real gender differences in empathy as indicated by physiological measures.

Gender differences in empathy are more obvious in adolescents and young children; girls are reported to be more empathetic than boys. Mestre et al. (2009) found that girls between age

13 and 16 scored higher on self-report measures of CE and EE. Parental ratings of their 4 to 11 year-old child’s empathy on the empathy quotient that assesses CE also yielded higher scores for

23 girls (Auyeung et al., 2009). Higher scores for 5 year-old girls, compared to like-aged boys, were also found on a composite empathy score that included parental ratings and child verbal responses to an emotional video. Even in young children (i.e., 19 to 25 months), girls were more likely than boys to express concern and show helping behaviors when their primary caregiver pretended to be in (Volbrecht, Lemery-Chalfant, Aksan, Zahn-Wexler, & Goldsmith, 2007).

Genetics. Similar empathy levels were greater among identical twins than non-identical twins in response to simulated distress levels measured at two points when the infants were 14 and 20 month-old, which indicates a possible genetic predisposition in the development of empathy (Zahn-Waxler et al., 1992). Furthermore, By 24 and 36 months of age, heritability was found to be associated with one third to almost one half of the variation in children’s empathy, indicating the importance of genetic influences of empathy development (Knafo et al., 2008).

Neural development. There are several brain areas implicated in empathetic development and behavior; any damage or dysfunction in these brain areas can result in poor empathetic responses. A special class of motor neurons - mirror neurons located in the frontal lobe of the brain - are thought to play a role in empathy development. When a person is observing someone’s emotional experience, the mirror neurons will fire in the observer’s brain causing automatic and unconscious activation of one’s personal associations with that state, and hence reacting to the other’s emotional state as if it is one’s own (Preston & de Waal, 2002).

However, to induce empathy, mirror neurons must communicate with many other areas in the brain. The insular cortex connects the mirror neurons to the limbic system, which is responsible for the emotional aspect of empathy (Carr, Iacoboni, Dubeau, Mazziotta, & Linzi, 2003;

Iacoboni & Dapretto, 2006).

24 In order to experience empathy and not become overwhelmed with emotional distress, neural pathways responsible for emotion regulation also must be activated. The prefrontal cortex reduces personal distress when viewing another’s distress, allowing the observer to connect on a more cognitive level and aids in helping behavior (Decety & Jackson, 2004). Other areas involved in the reduction of personal distress are those responsible for self-other differentiation, namely the posterior cingulate, the precuneus, and the right temporo-parietal junction (Decety &

Jackson, 2004). In order to engage in cognitive empathy, areas of the frontal and parietal lobes involved in executive functioning need to be activated. These include the frontopolar cortex, the ventromedial prefrontal cortex, the medial prefrontal cortex, and the right inferior parietal lobe

(Decety & Jackson, 2004). During this process, areas of the temporal lobe are also activated, providing access to long-term memories that may be relevant to the situation (Preston & de

Waal, 2002).

Temperament. Temperament, which constitutes a variety of attributes that form the early basis of personality development, has been linked to empathetic abilities. Individual differences in empathy based on temperament may reflect genetic influences, since it is thought to be present from birth (McDonald & Messinger, 2012). Infants that display fearfulness were found to have empathetic concern for others when they reached school age as reported by their parents (Rothbart, Ahadi, & Hershey, 1994). Similarly, school-age children who were shy were rated by their parents as being more empathetic than other children (Cornell & Frick, 2007); however, shy toddlers were found to be less likely to engage in empathic and helping behaviors with a stranger in a simulated distress situation (Young, Fox, & Zahn-Wexler, 1999). These findings suggest that shy children are more likely to display empathic behaviors in a familiar context, such as towards their parent than to another’s distress in unfamiliar situation (McDonald

25 & Messinger, 2012). Reactivity has also been linked to empathy. Reactivity refers to the degree to which one physiologically responds to stimuli in their environment. For example, infants that show low levels of motor and emotional response to sensory stimuli at four months are less empathic to stranger’s distress at age two (Young et al., 1999).

Parenting. Parenting influences the early development of empathy since parents and caregivers have a significant socializing influence on their children. One aspect of the parent- child interaction that influences the development of empathy is synchrony, which is the fit or the match between the mother’s and infant’s emotional state (Feldman, 2007). It was found that mother-infant synchrony in the first year of life (i.e., 3 to 9 months) was directly associated with empathy level, especially EE, in later childhood and adolescence (i.e., 6 to 13 years). More specifically, the more mothers and infants matched and influenced each other behavior during face-to-face play in infancy, the more empathy the child expressed during childhood and adolescence as measured in a laboratory-based empathy task (Feldman, 2007). Furthermore, parents who display more warmth to their children, provide a model for being sensitive to others’ needs and feelings. Also parents who talk about emotions with their children are more likely to have empathetic children (Garner, 2003).

The security of the child’s attachment to the parent is another factor that influences the development of empathy. Securely-attached children who display behaviors consistent with a loving and trusting relationship with the parent, were found to engage in more empathic responding and have inhibited personal distress, than insecurely attached children (i.e., anxious avoidant) (Kestenbaum, Farber, & Sroufe, 1989; Mikulincer et al., 2001). Interestingly, the effect of child’s security in displaying empathic behaviors is stronger than the effect of temperament.

Temperamentally shy children, who tend to show low empathetic behaviors to strangers, were

26 found to respond empathetically to others’ distress in an unfamiliar situation if they grew up in a secure environment. The opposite was true for fearful children who had insecure attachment styles (i.e., they showed less empathetic concern for strangers) (van der Mark, van IJzendoorn, &

Bakermans-Kranenburg, 2002).

Parental Acceptance-Rejection.

One aspect of parenting that influences the development of empathy is the child’s perception of his/her parent’s warmth or acceptance. The construct of parental acceptance- rejection was studied specifically in relation to EE but not CE. Early research studies reported that the development of EE is facilitated in families where children experience warmth, , nurturance, and overall parental acceptance (Barnett, King, Howard, & Dino, 1980;

Bryant, 1987; Eisenberg, 1992; Eisenberg & Mussen, 1989; Grusec, 1981; Trommsdorff, 1991).

Parental acceptance refers to the amount of affection and warmth that a parent displays towards his/her child. Accepting parents are those who usually smile at, encourage, and praise their children, while limiting their criticism, punishment, and signs of disapproval (Arzeen et al.,

2012). In contrast, rejecting parents are found to diminish the development of empathy in their children. These parents usually criticize, punish or ignore the child’s physical and emotional needs, leading the child to feel rejected (Rohner, 1975).

Parental Acceptance-Rejection Theory (PARTheory) by Rohner (1975) explains the association of parental acceptance-rejection with emotional empathy. PARTheory is a bipolar dimension of parental warmth, with parental acceptance at the positive end of the continuum and parental rejection at the negative end. It proposes that human beings have a fundamental need for , warmth, and approval from people who are most important to them (i.e., attachment figures). These traits (i.e., love, warmth, and approval) constitute the acceptance behavior of

27 parents towards their children, which consequently affects the child’s psychological adjustment, including behavioral and emotional functioning (Rohner, Khaleque, & Cournoyer, 2010).

PARTheory predicts that children who come from accepting families are more likely than children who come from rejecting families to develop positive self-esteem, competence, intimate and trusting relationships, and prosocial behaviors, such as empathy, compassion, and altruism

(i.e., emotional responsivity), and to view the world in a positive manner.

In contrast, parental rejection can occur in four ways according to PARTheory. One is in the form of coldness and lack of affection (i.e., the reverse of warmth and affection). A second is in the form of (i.e., feelings of or toward child) and verbal and physical (e.g., saying cruel remarks to their child, hitting, or pushing). The third is in the form of indifference (i.e., lack of concern or interest in the child) and neglect (i.e., physical or psychological remoteness from the child). The final way is undifferentiated rejection, which refers to forms of parenting that do not clearly demonstrate neglect, indifference, aggression, or a lack of affection, but nonetheless leaves the child feeling not cared for or unloved (Rohner et al.,

2005). PARtheory is an evidence-based theory that has been widely supported by research assessing children and adolescents of varying age, gender, race, and culture, especially in the areas of substance abuse and behavioral problems, including conduct disorder, externalizing problems, and delinquency (Khaleque & Rohner, 2002; Rohner, Khaleque, & Cournoyer, 2012).

Research studies assessing the parenting role in the development of empathy among adolescents have been sparse (Arzeen et al., 2012). In a study by Arzeen et al. (2012), parental acceptance-rejection was investigated among empathetic versus non-empathetic adolescents in the age group of 13 to 17 years old. Findings showed that perceived parental acceptance was higher among emotionally empathetic adolescents compared with non-empathetic adolescents.

28 Furthermore, emotionally empathetic adolescents scored lower on perceived parental undifferentiated rejection and parental neglect, and perceived their parents to be less aggressive

(Arzeen et al., 2012). Similar findings were reported in a study of college students’ (i.e.,19 to 21 years old) perceptions of their parents’ acceptance. EE correlated positively with their perception of being accepted by their parent in their childhood; however, the gender of the parent and the child played a role in the relationship between EE and perceived parental acceptance.

Mothers, but not fathers, who were perceived as accepting during a youth’s childhood produced more empathetic college-age daughters, but not sons. Similarly, the more accepting fathers, but not the mothers, were perceived by subjects during their childhood, the more EE college-aged sons displayed; this was not true for fathers and their daughters (Kim & Rohner, 2003). Although no significant relationship between the gender of the parent and that of the adolescent was found in the study of Arzeen et al. (2012), the emotionally empathetic adolescents of both genders perceived their mothers to be more accepting than their fathers.

Parental acceptance-rejection was studied in relation to the symptoms related to MDD,

ODD, and ADHD in youth, but not to their empathetic responses. The majority of research on parental acceptance-rejection focused on global indices of the child’s behavioral problems, such as delinquency and aggression. For example, Shaw et al. (1998) found that rejection from the mother was a significant predictor of externalizing behavior 18 months later. More recently, a significant relationship was found between both mother and father rejection and child aggression in a community sample of children aged 9 to 12 years old (Roelofs, Meesters, ter Huurne,

Bamelis, & Muris, 2006). Finally, in a cross sectional study of adolescents, which examined a number of dimensions of the parent–child relationship and externalizing behavior, Muris,

29 Meesters, and van den Berg (2003) found that the strongest correlation was between perceived parental rejection and externalizing behavior.

Only one study included the symptoms and behaviors of subjects with ADHD in relation to their perception of parental acceptance or rejection. In this study of school-age children, findings show that the more children displayed ADHD symptoms, as reported by their parent, the more the child perceived the parent as rejecting. (Lifford, Harold, & Thapar, 2008). Perceived parental rejection in childhood has been found to be associated with the development of depressive symptoms in children, adolescents, and adults of both genders, but more often among female adolescents and adults (Reinherz, Giaconia, Hauf, Wasserman, & Silverman, 1999). For example, in a large community-based study, girls whose mothers were low in warmth and support demonstrated an increase in MDD symptoms over a 4-year period from late childhood to adolescence (Ge, Lorenz, Conger, Elder, & Simons, 1994). Similarly, Hipwell et al. (2008) reported that low parental warmth predicted increases in a child’s depressive symptoms over a 6- year period from ages 7 to 12. It is suggested that perceived parental rejection is associated with the child’s negative thoughts about one’s personal worth, competence, and views about life and the world (Rohner & Britner, 2002). The protective influence of parental warmth and affection was reported to be associated with less depressed mood across different age groups and reduced effect of stressful life events of the offspring (Belsky & Pensky, 1988; Greenberger & Chen,

1996).

The influence of parental rejection on individuals with ODD has not been investigated directly; however, it can be inferred from studies on the association of parental rejection with child’s behavioral problems including delinquency and conduct problems, as these behaviors

30 tend to involve elements of defiance, disobedience, and negativistic behavior, which are characteristics of individuals with ODD. Across different cultures, empirical findings strongly implicate parental rejection as a major predisposing factor in almost all forms of behavior problems. Rothbaum and Weisz (1994) demonstrated this forcefully in their meta-analysis of 47 studies that studied associations between parental acceptance-rejection—and children’s externalizing behaviors including aggression, hostility, and noncompliance. Findings in the vast majority of studies reviewed showed a significant association between parental rejection and children’s externalizing behavior problems. This conclusion holds true across a variety of discrete measures (e.g., self-report questionnaires, interviews, and direct observations) and across an array of research designs (e.g., cross-sectional studies, longitudinal studies, and experimental studies). Therefore, parental rejection tends to be associated with children who are hostile and aggressive. The relationship may be reciprocal in that the more children behave in hostile and aggressive ways; the more parents tend to withdraw their warmth and affection

(Rothbaum & Weisz, 1994).

No study thus far has controlled for the effect of parental acceptance-rejection on EE and

CE in adolescents with ADHD or ADHD with comorbid ODD and MDD. Although the development of empathy and display of empathic behaviors are considered impaired in individuals with ADHD, ODD, and MDD, research in this area focused on these disorders separately and the majority of studies failed to assess whether gender differences existed.

Studying and differentiating the empathetic profiles of adolescents diagnosed with ADHD with and without comorbidities and the role of gender in empathic abilities in these disorders is lacking. Furthermore, inconsistencies on the reported empathetic impairments (i.e., EE, CE, or both) of these disorders are evident and further research is needed in this area.

31 Empathy in ADHD

Braaten & Rosén (2000) used fictional stories to assess empathetic response among 6 to

12 year-old children with ADHD; the fictional stories attempted to elicit both positive and negative feelings. The subjects were asked to answer questions about the feelings of the character in the story (e.g., “How does the character feel?”), their own feelings (e.g., “How does the character make you feel?”) and the reason for their feelings (e.g., “Why does the character make you feel this way?”). Children with ADHD were less likely than those without ADHD to match their emotions with the emotions of the child in the story and gave significantly fewer character-centered interpretations. Interestingly, children with ADHD were able to match their feelings with the story that elicited happy feelings, although they performed poorly in interpreting the positive emotions. No group differences were found between children with

ADHD and controls on self-report measures of emotional reactions to reward and punishment situations applied to oneself (Braaten & Rosen, 2000). Several implications can be drawn from the findings in this study. First, since children with ADHD gave poorer interpretations of the character’s feelings, this might suggest a deficit in their ability to take the perspective of others

(i.e., impaired CE). Second, a heightened EE might be present in ADHD children, since it was easier for them to match their feelings when the story elicited happy, but not negative feelings.

Some studies found that children with ADHD experience difficulties in identifying emotional facial expressions, especially for facial expressions of anger, , and sadness. (Aspan et al.,

2014; Boakes, Chapman, Houghton, & West, 2008; Pelc et al., 2006).

In the study of Clark et al. (1999), 47 boys and 2 girls with ADHD, ages 5 to15 years, found that “lack of awareness of other’s feelings” was the most reported symptom by parents.

However, about two thirds (63.6%) of this sample were also diagnosed with CD or ODD. One

32 implication of the findings is that these two comorbidities (i.e., ODD and CD) may explain the poor empathic responses exhibited by children with ADHD (Clark et al., 1999). Furthermore, although this sample of children with ADHD were not diagnosed with comorbid Autism

Spectrum Disorder (ASD), they possessed many autistic symptoms. This raised concerns about whether these subjects also had ASD, a common comorbidity of ADHD, which may explain the findings (i.e., poor empathetic responses).

In another study (Marton et al., 2009), a sample of 50 children with ADHD in the ages of

8 to 12 years, reported lower levels of social perspective taking and identification of others’ feelings compared to typically developing children, even after controlling for the role of language abilities, intelligence and oppositional and conduct problems. Females scored higher than males on the empathy tasks (Clark et al., 1999; Marton et al., 2009). The lack of CE in children and adolescents with ADHD, regardless of cognitive functioning and comorbidities with oppositional and conduct problems, were reported in a recent meta-analysis that lended some support to the notion that children with ADHD suffer from emotional recognition and understanding deficits (Graziano & Garcia, 2016). Interestingly, a recent study assessed only emotional empathy in response to sadness and distress in school aged children with ADHD, but without comorbidities of ODD or conduct disorder, and found that these children were impaired in EE according to the teacher’s but not to their parents’ reports (Deschapms, Schutter,

Kenemans, & Matthys, 2015). The study attributed such differences in parent’s and teacher’s reports to the type of setting in which school setting is considered more complex and socially demanding that requires more social and prosocial responding to peers than home (Deschapms et al., 2015).

33 In an investigation by Yuill and Lyon (2007), 5 to 11 year-old boys with ADHD who were age-matched with typically developing boys, were presented with emotional (e.g., Happy:

Thomas has just found his lost puppy) and non-emotional situations (e.g., Hot: Thomas has just been out in the sunshine). They were instructed to match emotional facial expressions to the character of the story (i.e., emotional task) and to make an inference about a physical property of the character’s face, such as inferring that someone with a sticking plaster on their face may have been scratched (i.e., non-emotional task). Children with ADHD performed more poorly than the control group in the emotional task; however, they also showed impairments when they had to make judgments about non-emotional characteristics of faces. The authors of this study hypothesized that impulsivity in ADHD children might be the underlying reason for poor performance on these tasks. Therefore, the second part of the study was to control the impulsivity of the children in the sample. Findings showed that, although such procedure helped children with ADHD to perform better in the non-emotional task, they still experienced difficulties with the emotional task (i.e., to match emotional eliciting situations with facial expressions) (Yuill & Lyon, 2007). Such deficits were attributed to specific brain regions dysfunction, specifically the dysfunction in the fronto-striatal area in the brain, which controls executive functions, including those responsible for emotional processing, and not merely to impulsivity (Uekermann et al., 2010). These findings were similar to those of Casey’s (1996) study where children with ADHD performed worse than controls in identifying the emotions of the characters in a story and in selecting facial drawings depicting the feelings of the character.

Even when presented with other forms of non-verbal cues of tasks, such as recordings of voice, children with ADHD were less accurate at interpreting emotions than controls due to failure in attending to appropriate cues of affect (Cadesky, Mota, & Schachar,

34 2000). Another study went beyond investigating the ability of children and adolescents with

ADHD to recognize facial expressions to assess their capability to recognize emotions based on contextual cues (Da Fonseca, Seguier, Santos, Poinso, & Deruelle, 2009). The results of this study showed that children and adolescents, aged 5 to 15 years old, were less accurate than controls in identifying emotions from facial expressions and using contextual information to understand emotions (Da Fonseca et al., 2009).

In a study by Singh et al. (1998), performance of children with ADHD on the emotion task was higher. Fifty children and adolescents with ADHD in the age range of 5 to 13 years old correctly identified 74% of the emotions, especially . The high percentage of correct responses may be attributed to the nature of the task requirement. Singh et al. (1998) required their subjects to only match faces to an emotion label. In other studies, such as the one by Yuill and Lyon (2007), children were given a task that was more similar to an everyday situation.

Responding empathetically to a task that resembles everyday situation is considered more complex than labeling emotions (e.g., happy, sad) since the prior requires emotional understanding of why the character feels the way he/she feels (i.e., CE). For example, a child with ADHD may recognize an expression (e.g., distress in a peer), but does not understand why the peer feels distressed (Yuill & Lyon, 2007), implying a deficit in CE. However, the differences in the findings of these two studies can also be attributed to the nature of the study sample. In the study of Yuill and Lyon (2007), some of the subjects had a comorbid diagnosis of

ODD, while Singh et al. (1998) failed to screen for comorbidities.

Assessing empathy in subjects with ADHD was also studied in a natural context (e.g., playground) (Cordier, Bundy, Hocking, & Einfeld, 2010). Similarities and differences in social interaction between children with ADHD in the age range of 11 to 15 years and matched controls

35 (i.e., age, gender, and ethnicity) were studied. Children with ADHD were found to be less skilled in social play than their counterparts. Poor social play performance was not attributed to ADHD symptoms (i.e., hyperactivity, impulsivity, and inattention) or lack of social skills. Instead, difficulties in social play were thought to result from the lack of both CE and EE. Lack of EE was demonstrated in the difficulties to respond to others’ play cues, support others’ play, and share ideas and resources, as well as in superficial and destructive interactions with their peers.

Deficits in CE were demonstrated in the unawareness of children with ADHD that other players might like to take a turn in the game they possess. These results are in line with those of the study by Maoz, Gvirts, Sheffer, and Bloch (2017), which concluded that there was impairment of both CE and EE in children with ADHD as they scored lower than healthy controls on all interpersonal reactivity index (IRI) subscales of empathy except for personal distress. In contrast,

Gambin and Sharp (2016) reported that symptoms of ADHD were positively related to EE but not CE in inpatient adolescents.

Maoz et al. (2013) differentiated the severity of empathetic impairments among ADHD-

C and ADHD- I subjects using the IRI scale. This scale is composed of two CE subscales (i.e., perspective taking and fantasy) and two EE (i.e., empathetic concern and personal distress).

Children with ADHD-C scored lower on the IRI total scale and on the fantasy scale than children with ADHD-I, which taps the subject’s tendencies to transpose themselves imaginarily into fictional situations (Maoz et al., 2013). However, findings in this study failed to report the scores of the EE subscales between the two ADHD groups. The study of Braaten & Rosén (2000) also reported that ADHD-C is a qualitatively different disorder with more social and empathetic impairments than ADHD-I, and hence subjects with ADHD-I were excluded from their study.

These findings are in line with the ADHD literature in which subjects with ADHD-C have been

36 found to show poorer social problem-solving skills, impulsive responding, and more conduct problems compared to children with ADHD-I (Barkley, 2006). Furthermore, parents and teachers were found to attribute poorer social skills and more social difficulties to children with ADHD-C than to children with ADHD-I (Maedgen & Carlson, 2000; Semrud-Clikeman, 2010).

Empathy in ODD

The literature on empathy in children and adolescents with ODD is scarce. Studies informing the nature of empathy in this population can be inferred from studies on empathy in subjects with disruptive behavior disorders (DBD). DBD is a group of disorders characterized by problems in emotional and behavioral self-control. Prior to the introduction of the DSM-V, this category of disorders included ODD, conduct disorder (CD), and disruptive behavior disorder not otherwise specified (DBD-NOS). Disruptive behavior disorders were changed in the DSM-V to a wider range of disorders under a new category entitled “Disruptive, Impulse Control, and

Conduct Disorders.” Studies assessing empathetic profiles in children and adolescents with DBD included only those subjects diagnosed with ODD and CD.

The few studies that investigated empathy in DBD population focused mainly on EE and used physiological measures in addition to self-report questionnaires. The majority of these studies included only boys with ODD and CD in the age range of 8 to 12 years old. Physiologic measures included the recording of heart rate (HR) and facial electromyographic (EMG) reactivity in the cheek and eyebrow muscles during sadness-, anger-, or happiness-inducing film clips of dynamic emotional facial expressions. Normally, the cheek muscle activity is increased during exposure to happy facial expressions, whereas angry and sad facial expressions evoke increased eyebrow reactivity. In these studies and relative to controls, DBD subjects showed lower empathetic responses for anger and sad facial expressions, but not for happy faces. More

37 specifically, the eyebrow muscle response to angry and sad facial expression was less profound for DBD subjects than controls, and no significant differences between the two groups emerged in the cheek muscle response to happy faces. In regard to the heart rate reactivity, DBD subjects showed significantly less cardiac deceleration than normal controls in response to the negative facial expressions (i.e., sad and anger) (de Wied et al., 2009; de Wied et al., 2006). It is hypothesized that deceleration in the sympathetic branch of the autonomic nervous system beyond a certain point is related to less empathy or high distress (Blair, 2007; Christie &

Friedman, 2004). These findings show that individuals with DBD are less emotionally responsive to others’ distress than controls.

Self-report measures assessed only the emotional component of empathy in DBD children and adolescents between 8 and 12 years old. In these studies, subjects with DBD significantly scored lower and reported fewer concordant emotional responses than controls, supporting the observations that individuals with DBD are weak empathizers (de Wied, et al.,

2005; de Wied et al., 2006). One recent study investigated EE in response to sadness and distress in school children with DBD, aged 6 to 7 years old, using parent and teacher report of

EE; findings showed that both parents and teachers rated these children lower on EE than controls, even after controlling for ADHD symptoms (Deschapms, Schutter, Kenemans, &

Matthys, 2015).

Both EE and CE was assessed in one study of 8 to 12 year-old boys using six empathy- inducing vignettes displaying sadness, anger or happiness. The subjects were asked: (a) to identify the type and intensity of the emotions of the protagonist; (b) to report the type and intensity of emotions they had experienced themselves the moment the protagonist expressed his or her emotions; and (c) to state why he had felt the emotion(s) reported. Compared to controls,

38 boys with DBD responded less empathically to sadness and anger, but equally empathically to happiness feelings. Furthermore, children and adolescents with DBD were found to lack the ability to take the perspective of others (i.e., impaired CE) (de Wied et al., 2005). The samples in these studies included only boys with DBD, except for one study (Deschapms et al., 2015) that overlooked investigating gender differences in empathy among this population.

Empathy in MDD

Several studies investigated the nature of empathetic responses in individuals with MDD; however, these studies focused only on adults with MDD. Multiple mechanisms for the underlying empathetic deficits in this population have been suggested, including neurobiological and psychological pathways. The nature of empathetic deficits varied and was inconsistent.

Some of the studies focused on understanding the CE and this component was measured using theory of mind (ToM) tasks. Broadly constructed, ToM refers to the everyday ability to ascribe mental states (e.g., beliefs, emotions, and intentions) to others and to understand and predict their social behavior (Lee, Harkness, Sabbagh, & Jacobson, 2005). The majority of these studies reported impairment of CE in this population. Inoue et al. (2006) suggested that impairments in

ToM may continue to exist when patients are in remission and predict relapse. Specifically, researchers found that individuals with MDD were impaired in recognizing facial emotions.

These studies required subjects to either match a photograph to one of an array of photographs that depicted various facial expressions (Rubinow & Post, 1992), or to determine whether pairs of faces were similar or different (Asthana, Mandal, Khurana, & Haque-Nizamie, 1998;

Feinberg, Rifkin, Schaffer, & Walker, 1986). Poor facial emotion-recognition has been identified as a possible factor underlying social difficulties in individuals with MDD (e.g.,

39 Deldin, Keller, Gergen, & Miller, 2000). However, Asthana et al. (1998) related poor CE in individuals with MDD to visuospatial impairment indicating possible dysfunction in the right hemisphere of the brain as these subjects were also impaired in visuospatial pattern-matching task involving simple non-face patterns (Marcel, Samson, Cole, & Schatzberg, 1993). From the findings of these studies, it is unclear whether individuals with MDD have a specific impairment of recognizing facial expressions or they lack a general task-recognition related to visual perceptual disturbances.

Other studies that examined CE in MDD reported different patterns of results. For example, several studies found that individuals with MDD were biased to preferentially identify negative emotions (Bouhuys, Geerts, & Mersch, 1997; Bouhuys, Geerts, & Gordijn, 1999; Gur et al., 1992; Mandal & Bhattacharya, 1985; Hale, 1998). The paradigm employed in the majority of these studies required subjects to recall memories of emotions or freely label emotion terms, processes that are compatible with the negative thought processes inherent in MDD and independent of emotion-recognition tasks (Dalgleish & Watts, 1990). Another study found that subjects with MDD were impaired in identifying emotional states from pictures of eyes, including positive, neutral, and negative emotions. Furthermore, the findings of this study contradicted the notion that MDD is associated with visuospatial dysfunction as individuals with

MDD did not differ from healthy controls in correctly identifying the non-emotional task (i.e. identifying gender from the eyes region) (Lee et al., 2005).

Various functional neuroimaging studies attributed the impairments in CE in individuals with MDD to structural and functional abnormalities in frontal brain regions (Frith & Frith,

2006; Gallese, Keysers, & Rizzolatti 2004; Singer, 2006; Zaki, Weber, Bolger, & Ochsner,

2009). Specifically, impaired executive functions, such as poor working memory and

40 inflexibility of the frontal brain area, are suggested to be responsible for the poor perspective taking abilities in persons with MDD (Thoma et al., 2011; Zobel et al., 2010). In contrast, findings in two studies showed no differences between individuals with MDD and healthy controls in their performances during an emotion recognition task (Doody, Gotz, Johnstone,

Frith, & Cunningham, 1992; Gaebel & Wolwer, 1992). For example, Gaebel and Wolwer (1992) exposed subjects with MDD to pictures of facial expressions of females and males expressing six basic emotions (i.e., happiness, sadness, , fear, , and anger). The subjects were able to correctly identify the corresponding emotions and imitate them.

Subjective measures of CE also showed inconsistent findings. The majority of findings showed no significant differences in responses of CE between individuals with MDD compared to healthy controls (Schneider et al., 2012; Thoma et al., 2011; Wilbertz et al., 2010). Findings in several other studies reported reduced CE in the MDD population compared to healthy controls

(Cusi et al., 2011; Donges et al., 2005). For example, Cusi et al., (2011) used two subjective measures of empathy, the IRI and the Toronto Empathy Questionnaire. Compared to matched controls, patients with MDD reported significantly reduced levels of perspective taking as captured by the IRI. Interestingly, the group difference existed even though depressive symptom levels in subjects were low at the time of the assessment.

Researchers who studied EE in subjects with MDD used the two subscales of the IRI, empathetic distress and empathetic concern. In the majority of these studies, subjects with MDD reported significantly higher levels of empathetic distress compared to healthy controls; their scores on empathetic concern did not differ from the control group (Derntl et al., 2012; O'Connor et al., 2002; Schneider et al., 2012; Thoma et al., 2011; Wilbertz et al., 2010). In another study, empathetic distress and concern for subjects with MDD were low (Cusi et al., 2011).

41 Thoma et al. (2011) administered the Multifaceted Empathy Test (MET), which assesses

EE in a standardized hypothetical situation, and subjects with MDD had similar scores to those in the healthy control group in emotional concern but they scored higher on personal distress.

Empathetic distress in MDD is explained as the patient’s inability to separate their own emotional experience from those of others. Therefore, when individuals with MDD encounter the emotional pain of others, they react by imagining their reaction to a similar situation they experienced in the past. In this situation, depressed people are inclined to re-experience past emotional pain. To reduce such pain, these individuals will withdraw from the situation and may avoid similar situations in the future (Schreiter, Pijnenborg, & aan het Rot, 2013). Therefore, both studies of Thoma et al. (2011) and Schreiter et al. (2013) concluded that individuals with

MDD have empathic concerns for others, but due to high personal distress, they avoid such experiences. Only one of the above mentioned studies explored gender differences in empathy among subjects with MDD and found that women reported higher personal distress in response to others’ negative feelings more than men (Bouhuys, Geerts, & Gordijn, 1999).

Summary of the Empathy Literature

Empathy is considered an important component for the development of effective social communication and interpersonal relationships. Impairments in empathy adversely affect the quality of social communication and functioning (Pfeifer, Iacoboni, Mazziotta, & Dapretto,

2008). Social communication is considered a vital area for human development and success, and adequate social functioning is considered a primary condition for children's optimal development

(Hattori et al., 2006; Parker & Asher, 1987). Impairments in social communication have long- term consequences and can lead to poor interpersonal relationships, low self-esteem and high

42 risk for suicide, difficulty in employment, marital dissatisfaction, and poor quality of life for patients and families (Pfeifer et al., 2008).

Difficulties in social interaction and functioning are profound in individuals with ADHD.

Children with ADHD have difficulties in peer relationships that often lead to peer rejection

(Barbaresi et al., 2007; Mrug et al., 2009). These social difficulties appear to be related to disruptive, impulsive, and noisy interaction patterns (Clark, Cheyne, Cunningham, & Siegel,

1988; Cunningham & Siegel, 1987). Peer rejection is also related to the aggressive behavior displayed by some children with ADHD (Miller-Johnson, Coie, Maumary-Gremaud, & Bierman,

2002). The majority of adolescents with ADHD are described to be lonely and report difficulties maintaining friends, leading them to have low self-esteem (Mrug et al., 2009). The social impairments continue into adulthood, leading to poor social competence and difficulties in employment and assertion skills (Friedman et al., 2003; Weiss et al., 1985). Social and interpersonal difficulties are even more severe when individuals with ADHD present with ODD or MDD comorbidities. Individuals with ADHD and ODD and MDD comorbidities are less socially competent and more aggressive, have more family-child and sibling conflicts, and demonstrate more negative peer interactions than those with ADHD alone (e.g., Becker et al.,

2015; Blackman et al., 2005; Pfiffner at al., 2005).

Empathy is also directly related to prosocial behaviors. These behaviors are characterized by positive responses to others’ needs and welfare, such as assisting, sharing, and being kind and considerate. Prosocial behaviors are important enabling process for altruism and the development of social relationships (Batson, 1991; Hay et al., 2010). It is suggested that early prosocial behaviors, as mediated by empathy-related responding, predict later prosocial predisposition in adulthood (Eisenberg et al., 2002). Furthermore, empathy and prosocial behaviors are negatively

43 correlated with aggression. Failure to empathize and learn prosocial behaviors can lead to aggression (Strayer & Roberts, 2004). Individuals with ADHD are unlikely to offer help and be concerned about others’ distress, less cooperative with peers, and display aggressive behavior in their social interaction with peers (Buhrmester et al., 1992; Paap et al., 2013). Although similar reactions were reported in individuals with ODD and MDD (Evans, Heriot, & Friedman 2002;

Kuhne et al., 1997; Hawker & Boulton, 2000), there is no account in the literature whether empathetic deficits are intensified or even different when these disorders accompany an ADHD diagnosis. Empathetic reactions in the three disorders (i.e., ADHD, ODD, and MDD) have been investigated separately, although ADHD comorbidity with these disorders is reported to be relatively high (e.g., Yang et al., 2011).

The majority of ADHD studies on empathy assessed CE using different measures, such as fictional stories, labeling the feeling according to a face in the picture, and matching feelings to a social situation. Findings in these studies showed impaired CE. Findings related to EE in

ADHD were mixed. Some studies reported the lack of EE among subjects diagnosed with

ADHD (Cordier et al., 2010; Maoz et al., 2017), while other studies showed heightened EE among this group, especially when presented with happy feelings (e.g., Bratten & Rosen, 2000,

Gambin & Sharp, 2016).

Some of the studies on empathy in ADHD did not differentiate whether poor empathetic abilities were related to the ADHD disorder itself or to its comorbidities and failed to account for gender difference. For example, in the study of Clark et al. (1999), 63% of the ADHD subjects fulfilled the criteria for either ODD or conduct disorder. Investigators in two studies (Brattan &

Rosen, 2000; Sing et al., 1998) failed to screen for comorbidities in their ADHD sample. The

Sing et al. (1998) study reported higher empathetic scores of subjects with ADHD than the study

44 of Yuill and Lyon (2007) in which some of the sample had comorbid ODD, making it difficult whether to attribute such differences to the nature of the ADHD disorder, the presence of the

ODD comorbidity, or to the task required. Another layer of complexity is added when the reported EE responses in subjects diagnosed with ODD, as reported from the DBD studies, are similar to those reported in the ADHD literature. Both groups of subjects with ADHD and DBD scored higher on matching happy feelings with the subject of the story, but not for negative emotions such as sadness. Therefore, it’s difficult to draw a conclusion about the possible differences of empathetic responses between ADHD disorder and ADHD with ODD comorbidity. Only two studies investigated gender differences among subjects with ADHD on empathy where females scored higher than males (Clark et al., 1999; Marton et al., 2009).

Although the majority of studies that investigated empathy in MDD reported impaired

CE in this population (e.g., Feinberg, Rifkin, Schaffer, & Walker, 1986; Lee et al., 2005), other studies reported subjects with MDD to be similar to healthy controls in their ability to take the perspective of others (Doody et al., 1992; Gaebel & Wolwer, 1992. High empathetic distress is well established among depressed individuals and usually attributed to the patient’s inability to separate their feelings from those of others. In contrast, empathetic concern for others in subjects with MDD was similar to healthy controls (Derntl et al., 2012; O'Connor et al., 2002; Schneider et al., 2012; Thoma et al., 2011; Wilbertz et al., 2010). No study thus far investigated empathetic responses in individuals with ADHD who have comorbid MDD, particularly in adolescence.

Since the empathetic profiles of each of these disorders (i.e., ADHD and MDD) are different in regard to empathetic concern (i.e., one component of emotional empathy), it’s important to assess the combined effect of both disorders on empathy, especially given that MDD is a relatively common comorbidity in the ADHD population (Barkley, 2006; Chronis-Tuscano et al.,

45 2010).

There are several design limitations in empathy studies in ADHD, ODD, and MDD populations. Methodological limitations related to the studies of empathy in ADHD include small sample size (Braaten & Rosen, 2000; Yuill & Lyon, 2007), lack of comparison of subtypes of ADHD (Marton et al., 2009), measurement issues (e.g., use of only one measure of empathy)

(Braaten & Rosen, 2000; Clark et al., 1999; Marton et al., 2009; Yuill & Lyon, 2007), gender disparity, high attrition rates, and presence of selection bias (Bratten & Rosen, 2000; Cordier et al., 2010; Clark et al., 1999). Researchers that discussed these limitations in their studies and cited limited generalizability, inability to differentiate empathy responses according to the developmental age as children and adolescents were combined together (de Wied et al., 2009; de

Wied et al., 2005), and experimenter bias (de Wied et al., 2005). Small sample size was the most frequent shortcoming in the studies of empathy in MDD (e.g., Cusi et al., 2011; Deldin et al.,

2000; Lee et al., 2005; O’connor et al. 2002; Wilbertz et al., 2010). Further limitations include large quantity of missing data (Schneider et al. 2012), failure to eliminate extraneous variables, such as from either the control group or the patients (Schneider et al. 2012;

Wilbertz et al., 2010), and using outpatient samples, which limit the generalizability of the study

(Lee et al., 2005). Most importantly, all of the studies that investigated empathy in MDD included only adults and failed to account for gender differences as well.

This study will be the first to compare empathetic response between adolescents with

ADHD-C, ADHD-C with ODD, and ADHD-C with MDD. Adolescents with ADHD-C will be included due to the reports in the literature that persons diagnosed with ADHD-C experience more severe social difficulties and empathetic impairments than those with ADHD-I. The strength of this study lies in its ability to: (a) include adolescent females and males; (b) account

46 for gender differences in empathy; (c) assess both CE and EE using IRI measure, which is a reliable, valid, and age-appropriate instrument for adolescents; and (d) explore the role of parental acceptance-rejection as perceived by the adolescents on their empathy responses.

Research Questions

This study will answer the following research questions:

1-Are there differences in CE based on gender, diagnosis, and the interaction among these two variables?

1a) To what extent does gender of the adolescents and their perception of their mother’s acceptance-rejection moderate the relationship between CE and diagnosis?

1b) To what extent does gender of the adolescents and their perception of their father’s acceptance-rejection moderate the relationship between CE and diagnosis?

2-Are there differences in EE based on gender, diagnosis, and the interaction among these two variables?

2a) To what extent does gender of the adolescents and their perception of their mother’s acceptance-rejection moderate the relationship between EE and diagnosis?

2b) To what extent does gender of the adolescents and their perception of their father’s acceptance-rejection moderate the relationship between EE and diagnosis?

47

Chapter 3

METHODOLOGY

48 Design

A comparative, cross sectional design was used to compare cognitive empathy (CE) and emotional empathy (EE) in adolescents with ADHD-C, ADHD-C with ODD, and ADHD-C with

MDD and investigate the role of gender and adolescent perception of parental acceptance/ rejection on empathy in this population. The following research questions guided the design of this study:

1-Are there differences in CE based on gender, diagnosis, and the interaction among these two variables?

1a) To what extent does gender of the adolescents and their perception of their mother’s acceptance-rejection moderate the relationship between CE and diagnosis?

1b) To what extent does gender of the adolescents and their perception of their father’s acceptance-rejection moderate the relationship between CE and diagnosis?

2-Are there differences in EE based on gender, diagnosis, and the interaction among these two variables?

2a) To what extent does gender of the adolescents and their perception of their mother’s acceptance-rejection moderate the relationship between EE and the diagnosis?

2b) To what extent does gender of the adolescents and their perception of their father’s acceptance-rejection moderate the relationship between EE and the diagnosis?

Sample and Setting

A convenience sample of adolescents diagnosed with ADHD-C, ADHD-C with ODD, and ADHD-C with MDD between 12 to 18 years of age was recruited from two settings: the

Neurodevelopmental Science Center (NDSC) in Akron, Ohio and Children’s Advantage in

Ravenna, Ohio. The NDSC is a department within Akron Children’s Hospital and it specializes

49 in providing care for children and adolescents in five specialties: developmental-behavioral , neurology, neurosurgery, physiatry, and behavioral and neuropsychology (Akron

Children’s Hospital, 2017). The developmental-behavioral pediatrics is an outpatient setting that treats, counsels, and evaluates children and adolescents with behavioral and developmental difficulties, including those with the diagnosis of ADHD. The services are provided through an interdisciplinary team including physicians, nurse practitioners, social workers, medical assistants, and patient representatives.

Children’s Advantage is a private, non-profit corporation that provides psychiatric mental health services to children and adolescents from birth to age 18 years and their families. This facility provides a wide range of outpatient and community mental health services including diagnostic assessment, counseling, pharmacological management and case management. These services are delivered through an interdisciplinary team of psychiatrists, nurse practitioners, licensed social workers, case managers, and a nurse.

Inclusion/Exclusion Criteria

Subjects were eligible to participate in this study if they were: (a) 12 to 18 years of age;

(b) diagnosed with ADHD-C, ADHD-C and ODD, and ADHD-C and MDD; and (c) able to read and understand English at seventh grade level. Subjects were excluded from this study if they had: (a) a diagnosis of mental retardation, since cognitive ability influences empathetic response in a positive direction (i.e., impaired cognitive ability results in low empathetic response) (Dyck,

Ferguson, & Shochet, 2001); (b) a history of foster home placement, as these adolescents may have attachment disorders that can confound empathetic abilities (Marcus, 1991); and (c) a comorbid diagnosis of Disorder (ASD) or Conduct Disorder (CD), since

50 individuals diagnosed with these disorders are reported to have low empathic responses (Dyck et al., 2001; Hummer et al., 2011; Schwenck et al., 2012).

Sample Size

The sample size of this study was determined using G*power 3.1 software for two-way

ANOVA test of three levels of diagnostic groups, ADHD-C, ADHD-C with ODD, and ADHD with MDD and two levels of gender. The criteria used to calculate the sample size for this study were a level of significance (α) of .05, power of .80, degrees of freedom of 2, and a medium effect size of .3. Since there were no research findings in the literature that compared empathetic responses between ADHD, ODD, and MDD, an effect size could not be calculated and the decision for using a medium effect size was made. G*power software calculation resulted in a total sample size of 117. A total sample size of 103 subjects were recruited and completed the study (i.e., 36 subjects with the diagnosis of ADHD-C, 36 subjects with the diagnosis of ADHD with MDD, and 31 subjects with the diagnosis of ADHD with ODD) after more than 12 months of recruitment at NDSC and Children’s Advantage. The decision was made not to engage a third site to recruit the remaining 14 subjects because of time limitations.

Variables and Measurement

Diagnostic Groups

Subjects’ diagnoses were made by their mental health provider according to the

Diagnostic and Statistical Manual of Mental Illness (DSM-5) and documented in each subject’s medical record. Three diagnostic groups were used. The first group were subjects who had a diagnosis of ADHD-C. The second group had a diagnosis of both ADHD-C and ODD; the third had ADHD-C and MDD.

51 Cognitive Empathy

CE was measured using two subscales of the interpersonal reactivity index (IRI) instrument (Davis, 1983): perspective taking subscale and fantasy subscale. Each subscale is composed of 7-items answered on a 5-point Likert scale, ranging from “Doesn’t describe me well” to “Describes me very well.” Perspective taking refers to the individual’s tendency to adopt the psychological point of view of others; while the fantasy scale taps the respondent’s tendency to transpose themselves imaginatively into the feelings and actions of fictitious characters in books, movies, and plays. A sample question of perspective taking reads, “I sometimes try to understand my friends better by imagining how things look from their perspective” and a sample fantasy question reads “I really get involved with the feelings of the characters in a novel.” (Appendix A). Reliabilities of these two subscales were reported widely above .70 (Fernández et al., 2011; Hawk et al., 2013). In this study, reliabilities of the perspective taking subscale and the fantasy subscale were .73 and.72 respectively using

Cronbach’s α. Convergent and divergent validity was well established in the literature through the existence of positive relationships between these two scales of CE and psychosocial functioning such as helping, openness, and agreeableness, and negative relationships with anxiety and (Fernández et al., 2011; Hawk et al., 2013).

Emotional Empathy

Emotional concern and personal distress subscales of the Interpersonal Reactivity Index the IRI (Davis, 1983) were used to measure EE. Each subscale is composed of 7-items and each item is answered on a 5-point Likert scale, ranging from “Doesn’t describe me well” to

“Describes me very well.” Empathetic concern assesses the individual’s concern for unfortunate

52 others and the personal distress subscale measures the respondent’s feelings of personal anxiety and unease in tense interpersonal settings. A sample question on empathetic concern reads, “I often have tender, concerned feelings for people less fortunate than me” and on the personal distress scale “I sometimes feel helpless when I am in the middle of a very emotional situation.”

(Appendix A). The internal consistency of these subscales were reported to be above .70

(Batanova & Loukas, 2012; Fernandez, Dufey, & Kramp, 2011). In this study, the emotional concern subscale had a reliability of .75 and personal distress subscale had a reliability of.74 using Cronbach’s α. Convergent and divergent validity was has been established through negative relationships of personal distress with self-esteem and and a positive relationship of emotional concern and psychosocial functioning (Fernández et al., 2011, Hawk at al., 2013).

Mother and Father Acceptance-Rejection

These two variables were measured using the mother and father versions of the Parental

Acceptance-Rejection Questionnaire: Child Version-Short Form (Child PARQ-Short) (Rohner,

1990). One version assessed the child’s perception of his/her mother’s acceptance-rejection

(Appendix B) and the other assessed the child’s perception of his/her father’s acceptance- rejection (Appendix C). Each version consists of 24 items that load onto four subscales:

Warmth/Affection, Hostility/Aggression, Indifference/Neglect, and Undifferentiated/Rejection.

Each item is rated on a 4-point Likert type scale from “almost always true” to “almost never true.” Both the mother version and the father version have the same exact items. Examples of scale items on both versions are: “my mother/father makes me feel wanted and needed”

(warmth/affection); “my mother/father goes out of his way to hurt my feelings”

(hostility/aggression); “my mother/father ignores me as long as I do nothing to bother him”

53 (indifference/neglect), and; “my mother/father does not really love me” (undifferentiated rejection). The questionnaire is keyed in the direction of perceived rejection and the scores of the subscale of warmth/affection are reversed coded so the higher the total score, the more rejection children tend to receive. Scores at or above 60 (the midpoint) on the PARQ-Short form signify the perception of more parental (maternal or paternal) rejection than acceptance. In this study, the subjects completed both versions of the PARQ-Short (i.e., the mother and the father version) unless the parent and adolescent indicated that the biological mother or father was not involved in the adolescent’s life. Involvement in the adolescent’s life was defined as: (a) the parent living in the same home as this child for the majority of the week, or; (b) the parent not living in the same home as the child for the majority of the week but has face-to-face contact with the child at least one time per month

Reliabilities for the four subscales in mother and father versions have been shown to be adequate in the U.S and internationally. Ronhner (1995) reported coefficient alphas of .76 (i.e., mother version) and .77 (i.e., father version), while alpha coefficients for the four subscales ranged from .78 to .94 (i.e., mother version) and .83 to .94 (i.e., father version). Furthermore, the average test-retest reliability across time periods ranged from 3 weeks to 7 years was reported to be .62 (Khaleque & Rohner, 2002). In this study, the reliabilities using Cronbach’s α of the four subscales of the mother’s version were as follows: (a) warmth/affection subscale (Cronbach’s α

= .88); (b) hostility/aggression subscale (Cronbach’s α = .76); (c) indifference/neglect subscale

(Cronbach’s α = .75): and (d) undifferentiated rejection subscale (Cronbach’s α = .69). The reliabilities of the father’s version for this study were: (a) warmth/affection subscale (Cronbach’s

α = .93); (b) hostility/aggression subscale (Cronbach’s α = .85); (c) indifference/neglect subscale

(Cronbach’s α = .86); and (d) undifferentiated rejection subscale (Cronbach’s α = .78).

54 Construct validity for this instrument through exploratory factor analysis yielded the same two factors: parental acceptance (i.e., warmth/affection) and parental rejection with its subscales of hostility/aggression, indifference/neglect, and undifferentiated rejection (Comunian & Gielen,

2001; Rohner & Chaki-Sircar, 1988; Rohner & Cournoyer, 1975).

Demographic and Clinical Data Sheet.

A demographic data sheet listed age, gender, ethnicity, and school grade of the adolescent was completed by the adolescent (Appendix D). A clinical data sheet containing current medication use and comorbid medical and psychiatric diagnoses was also used to document information from the subject’s medical record (Appendix E).

Recruitment and Data Collection Procedures

Recruitment Procedures

There were two recruitment phases due to difficulties achieving the required sample size.

In the first phase, the investigator worked closely with the research program director in the

NDSC to identify potential subjects who met the inclusion and exclusion criteria. An invitational letter, signed by the NDSC medical director, was sent via mail to the parent who was listed as the primary contact of each adolescent and met inclusion and exclusion criteria for the study. The invitational letter explained the nature and purpose of the study, its benefits, risks, voluntary nature, and the study procedure. Parents who believed that their adolescents were interested in taking part in the study called the investigator using a toll-free telephone number.

During the phone call, the study was explained in detail to the parent and questions were answered. Confirmation that the parent talked about the study with their adolescent and that the

55 adolescent showed interest in taking part in the study was obtained. An inquiry was made about the other biological parent’s physical presence and degree of involvement in the adolescent’s life to determine which the version(s) of the Child PARQ-Short would be administered during later data collection. For the purpose of this study, parental involvement was defined as living in the home with the child for the majority of the time every week or face-to-face contact with the child at least once a month if the parent doesn’t live with the child in the same house. For those who agreed to participate in the study, a date, time, and location (i.e., public library or the NDSC) were determined for informed consent and data collection. This initial recruitment strategy yielded only eight participants; therefore, a second, more active recruitment strategy was devised.

To increase the recruitment sample, the recruitment strategy was modified and two approaches were used in the second phase. The first approach involved meeting eligible subjects face-to-face just prior to their appointment times at the NDSC. The investigator met with a staff nurse employed in the NDSC who received IRB approval to assist in recruitment, informed consent, and data collection. The staff nurse was given detailed information about and trained in every aspect of the data collection procedure, including criteria for determining parental involvement and common questions being asked by previous participants and the answers to them. The staff nurse met with eligible subjects and their parents during the time of their appointment at the setting, explained the study, and asked about their interest in taking part in it.

In the second approach, Children’s Advantage was added as a second recruitment site.

The staff in this setting also were approved by the IRB to identify eligible subjects for the study.

Only the dates of the upcoming appointments of eligible subjects at Children Advantage were given to the investigator, who then met with the parent and the child face-to-face at the clinic

56 before the scheduled appointment time, introduced and explained the study to them, and inquired about their interest to participate in the study. For those who agreed, the researcher led the parent and the adolescent in a private room where the parent and the adolescent signed the consent forms. In this second phase, a total of 17 subjects refused to take part in the study due to either time constraints or no interest on the part of the adolescent to take part in the study. Two subjects were withdrawn from the study due to the refusal of the second parent to release their adolescent’s medical information when they were informed by their partner. The total sample size yielded during this second phase was 103 subjects.

Data Collection Procedures

After parental informed consent and adolescent informed assent was obtained, data collection immediately proceeded by the investigator or the staff nurse at the NDSC. The adolescent was given a private room to complete the questionnaires, which took approximately

20 to 30 minutes. Data collection instruments were compiled into one packet with clear instructions and wording of the questions. The instruments were administered in the following order: Interpersonal Reactivity Index, Parental Acceptance-Rejection Questionnaire, and

Demographic Data Sheet. Based on the information provided during recruitment by the parent and/or adolescent about the other parent’s degree of involvement, the adolescent completed either the mother version of the Child PARQ-Short, the father version of the Child PARQ-Short, or both. The investigator or staff nurse collected the instruments upon completion and reviewed each for missing data. Very few items on the questionnaires had missing data and for those that did contain missing data, the investigator or staff nurse asked the participant if he/she wished to answer the missing items or leave them blank. This strategy yielded very minimal missing data.

The first 64 subjects were compensated $25 gift card and the rest of the subjects were given $5

57 gift card. The reduction in monetary compensation of subjects was due to two reasons: a) recruiting more subjects to have sufficient power for the study, and b) scarcity of monetary funding allocated to this study. For parents who signed a consent form for releasing their adolescent’s child medical information, the clinical data sheet was completed from the subjects’ medical records at the clinical sites.

Ethical Considerations

Approval of the study from the Institutional Review Boards (IRB) at Akron Children’s

Hospital and Kent State University was obtained. The parent’s consent and adolescent’s assent was obtained before enrollment in the study. Confidentiality was maintained through assuring the parent and the adolescent that any information the adolescent provided would not be breached, unless there was evidence of harm to the adolescent or others. Furthermore, the information obtained from the adolescent was not revealed to the parent. Confidentiality was also assured through attaching identifiers to participants’ data instead of names, and reporting the findings of this study in aggregate form.

The study instruments had some items that had the potential of eliciting negative feelings for the participants. To minimize such psychological distress, this risk was identified in the consent forms and was disclosed to the parent and the participant. The adolescent was informed in advance that he/she could take a break from completing the instruments and come back to them when he/she was ready, or could refrain from answering the questions that may cause distress.

Beneficence of the study relies on the importance of its findings; this study provides more understanding on the empathetic abilities and/or deficits in adolescents with ADHD and

58 ADHD with comorbidities, and hence provides evidence for designing empathy-related interventions.

Data Management and Analysis

The Statistical Package for Social Sciences version 24 was used for data entry and analysis. Variable codes were included on the data collection form. Variable names assigned to items that make up a scale were assigned the same letters of the variable name. Double entry of data into two separate files was performed to identify inconsistencies and the data were also checked twice by the investigator. Data entry started shortly after data collection so that errors could be identified and strategies could be undertaken to eliminate them if possible, or to avoid extra errors. Categorical variables, such as gender, ethnicity, past and present counseling, were dummy coded.

Data were screened and corrected for outliers. Outliers were detected by examining frequency distribution, obtaining a histogram, and using box plots to look for unusual values.

The data had very minimal outliers; those that were identified were determined to be legitimate and hence included in the analysis. Data were also screened for missing values. The amount of missing data was very small and missing data were determined to be completely at random; therefore, pairwise deletion of cases was used when eligible during different types of statistical analyses.

Descriptive statistics of frequencies, means, range, and standard deviations were calculated to describe subjects’ demographic and clinical information. Mean scores and standard deviation around the mean were calculated for each group for CE, EE, and parental acceptance- rejection.

59 Two-way ANOVA was used to investigate the main effects as well as the interaction effect of gender and the diagnostic groups on the outcome variables (i.e., CE and EE). More specifically, this test was used to answer the following research questions: 1) Are there differences in CE based on gender, diagnosis, and the interaction among these two variables? 2)

Are there differences in EE based on gender, diagnosis, and the interaction among these two variables? Consequently, the assumptions of two-way ANOVA were examined. For example, the dependent variable should be a continuous variable, which corresponds to our variables of CE and EE. Other assumptions of two-way ANOVA include the normal distribution of the residuals and homogeneity of variance which refers to the equality of variances in the groups (Field,

2011). The normal distribution of residuals were examined using histogram, Q-Q plot, and normality tests of Kolmogorov-Smirnov and Shapiro-Wilk statistics. The results of these tests identified that the residuals for the dependent variables (i.e., CE and EE) were normally distributed for each level of the independent variables. Homogeneity of variance was examined using Levene’s test which concluded in the equality of variance on both cognitive and emotional empathy.

To test the moderating effect of adolescent gender and father and mother acceptance- rejection, hierarchal multiple regression analysis was used. Five steps were created for each of the variables in the following order: gender of the adolescent was entered in the first stage, followed by the diagnostic group, then parental acceptance-rejection, and in the fourth stage the interaction terms of gender with the diagnosis were entered, followed by the interaction terms of parental acceptance-rejection with the diagnosis. Assumptions of multiple regression are several, including normally distributed errors (i.e., residuals), interval or ratio measured dependent variable, linearity, homoscedasticity, and absence of multicollinearity between

60 predictors. Normality of residuals for CE and EE were met as indicated by histograms and normal P-P Plots. Linearity between the dependent variable and the predictors was assessed using scatter plots and was met as well. Multicolinearity was assessed by looking at the correlation coefficients between the variables and assessing the tolerance and VIF statistics. If tolerance is less than or equal to 0.1 and if VIF is more than or equal 10, it is indicative of multicolinearity (Field, 2013). It’s very common when including interaction terms that multicolinearity between the variables exist, which makes the interpretation of the results misleading and confusing (Williams, 2015). Therefore, to avoid multicolinearity, centering for the continuous independent variables was performed. Centering refers to subtracting the variable mean from each case so the new mean is zero (Williams, 2015). In this study, mother acceptance-rejection and father acceptance-rejection were centered and entered into the regression model as well as the interaction terms of these centered variables with the diagnosis.

The results of multicolinearity tests of the VIF and tolerance statistic after performing the centering procedure resulted in the absence of violations of this assumption.

The assumption of homoscedasticity means that the residuals at each level of the predictors have the same variance. This assumption was met for CE but was violated for EE.

Therefore, to have confidence in the parameter’s estimate and avoid misleading inferences

(Carpenter & Bithell, 2000), bootstrap analysis was used in the regression analysis for EE. This technique provided a confidence interval, or region which included the true parameter value with a specified probability (Carpenter & Bithell, 2000).

61

Chapter 4

RESULTS

62 Demographic Characteristics

The total sample size was 103 subjects. Ages of subjects ranged from 12 to 18 years (M =

14.6, SD = 1.8). The majority of subjects were male, n = 71, (68.9%) and Caucasian (86.4%).

The mean age of subjects in the three groups was comparable, 14.3 (SD = 2.14) years old for

ADHD-C, 14.7 (SD = 1.7) years old for ADHD-C/ODD, and 14.8 (SD = 1.6) years old for

ADHD-C/MDD. Approximately, 20% of subjects were in eighth grade. Caucasian was reported as the most common ethnicity for the three groups: 88.9% for the ADHD-C, 77.4% for the

ADHD-C/ODD, and 91.7% for the ADHD-C/MDD (See Table 1). No group differences were found regarding demographic data except for gender. The majority of subjects were male for the

ADHD-C (86.1%) and ADHD-C/ODD (74.2%), while female subjects constituted the majority of the ADHD-C/MDD group (52.8%). The proportion for gender was statistically different among the groups, X² (2, 103) = 13.28, p = .001. The ADHD-C/MDD group had higher female to male proportion (19 females, 17 males), while the other two groups had more male than female subjects, ADHD-C (31 males, 5 females) and ADHD-C/ODD (23 males, 8 females).

Table 1

Subjects’ Demographic Characteristics Characteristics ADHD-C ADHD-C/ODD ADHD-C/MDD Total n (%) n (%) n (%) n (%) Age group 12-14 22 (61.1%) 15 (48.4%) 13 (36.1%) 50 (48.5%) 15-16 5 (13.9%) 10 (32.3%) 15 (41.7%) 30 (29.1%) 17-18 9 (25.0%) 6 (19.4%) 8 (22.2%) 23 (22.3%) Gender Male 31 (86.1%) 23 (74.2%) 17 (47.2%) ** 71 (68.9%) Female 5 (13.9%) 8 (25.8%) 19 (52.8%) ** 32 (31.1%) School grade Grade 6 4 (11.1%) 4 (12.9%) 2 (5.6%) 10 (9.7%) Grade 7 9 (25.0%) 4 (12.9%) 4 (11.1%) 17 (16.5%) Grade 8 6 (16.7%) 6 (19.4%) 8 (22.2%) 20 (19.4%) Grade 9 5 (13.9%) 5 (16.1%) 5 (13.9%) 15 (14.6%)

63 Grade 10 2 (5.6%) 6 (19.4%) 9 (25.0%) 17 (16.5%) Grade 11 7 (19.4%) 2 (6.5%) 6 (16.7%) 15 (14.6%) Grade 12 3 (8.3%) 4 (12.9%) 2 (5.6%) 9 (8.7%) Ethnicity Caucasian 32 (88.9%) 24 (77.4%) 33 (91.7%) 89 (86.4%) African 2 (5.6%) 4 (12.9%) 2 (5.6%) 8 (7.8%) Hispanic 1 (2.8%) 1 (3.2%) 0 (0%) 2 (1.9%) Other 1 (2.8%) 2 (6.5%) 1 (2.7%) 4 (3.9%) Note. N =103. ADHD-C = Attention Deficit Hyperactivity Disorder-Combined Type; ADHD- C/ODD = Attention Deficit Hyperactivity Disorder-Combined Type and Oppositional Defiant Disorder; ADHD-C/MDD = Attention Deficit Hyperactivity Disorder-Combined Type and Major Depressive Disorder. **p < .01

Clinical Characteristics

A total of 18 subjects reported a coexisting medical diagnoses; asthma and allergic rhinitis each accounted for 22.2% of these diagnoses. Other medical diagnoses included migraine, seizures, gastroesophageal reflux disease (GERD), esophagitis, and osteochondritis.

Sixty four subjects had coexisting psychiatric disorders; anxiety disorders accounted for the highest percentage including anxiety disorder not otherwise specified (37.5%), post-traumatic stress disorder (14.1%), general anxiety disorder (12.5%), obsessive compulsive disorder (6.3%), (1.6%), and disorder (1.6%). Other coexisting psychiatric disorders reported by the subjects were learning difficulties (15.6%), substance use (4.7%), Tourette disorder (3.1%), simple tics and (1.6% each). The majority of the sample received past counseling (88.3%) and found it helpful (69.9%). Only fifty-five subjects received current counseling (53.4%) and of those, 89.1% found it useful.

The majority of subjects (95.9%) received medications related to treatment of ADHD, including stimulant and non-stimulant drugs. Stimulants were the most common medications prescribed, including Adderall (21.6%), Vyvanse (19%), and methylphenidate (13.8%). Fifty subjects (51.5%) were prescribed antidepressant medications; Prozac and Zoloft were the most

64 common drugs prescribed (26.9% each). Seventeen subjects received atypical antipsychotics including Seroquel (7.7 %), Risperdal (5.8 %), and Abilify (2.9 %). Coexisting medical diagnoses were most frequent in the ADHD-C/MDD group (16.7%). Anxiety disorders were the most common disorders in the three groups (43.3%) and ADHD-C/MDD subjects had the highest percentage of coexisting psychiatric disorders (69.4%). No significant differences were found between the groups regarding clinical data (See Table 2).

Table 2

Subjects’ Clinical Characteristics Characteristics ADHD-C/ ADHD-C/ ADHD-C ODD MDD Total n (%) n (%) n (%) n (%) Comorbid Medical Diagnoses Asthma 1 (20%) 1 (20%) 2 (25%) 4 (22.2%) Allergic rhinitis 2 (40%) 2 (40%) 4 (22.2%) Migraine 2 (40%) 1 (12.5%) 3 (16.7%) Seizures 1 (20%) 1 (12.5%) 2 (11.1%) GERD 1 (12.5%) 1 (5.6%) Esophagitis 1 (12.5%) 1 (5.6%) Osteochondritis 1 (12.5%) 1 (5.6%) Vestibular dysfunction 1 (20%) 1 (5.6%) Hemiplegia 1 (12.5%) 1 (5.6%) Comorbid Psychiatric Diagnoses Anxiety NOS 11 (45.8%) 4 (26.7%) 9 (36.0%) 24 (37.5%) PTSD 2 (8.3%) 4 (26.7%) 3 (12.0%) 9 (14.1%) GAD 2 (8.3%) 6 (24.0%) 8 (12.5%) OCD 1 (4.2%) 2 (13.3%) 1 (4.0%) 4 (6.3%) Social anxiety 1 (6.7%) 1 (1.6%) 1 (4.0%) 1 (1.6%) Learning difficulties 5 (20.8%) 4 (26.7%) 1 (4.0%) 10 (15.6%) Tourette 1 (4.2%) 1 (4.0%) 2 (3.1%) Simple tics 1 (4.2%) 1 (1.6%) Enuresis 1 (4.2%) 1 (1.6%) Substance use 3 (12.0%) 3 (4.7%) Stimulants Adderall 9 (14.5%) 8 (12.5%) 8 (9.1%) 25 (21.6%) Vyvanse 9 (14.5%) 6 (9.4%) 7 (8.0%) 22 (19.0%) Methylphenidate 4 (6.5%) 5 (7.8%) 7 (8.0%) 16 (13.8%) Antidepressants

65 Zoloft 3 (4.8%) 2 (3.1%) 9 (10.2%) 14 (26.9%) Prozac 2 (3.2%) 1 (1.6%) 11 (12.5%) 14 (26.9%) Atypical antipsychotics Seroquel 2 (3.2%) 3 (4.7%) 3 (3.4%) 8 (7.7%) Risperdal 5 (7.8%) 1 (1.1%) 6 (5.8%) Abilify 1 (1.6%) 2 (2.3%) 3 (2.9%) Past counseling Yes 27 (75.0%) 30 (96.8%) 34 (49.4%) 91 (88.3%) No 6 (16.7%) 1 (3.2%) 2 (5.6%) 9 (8.7%) Was helpful 24 (66.7%) 24 (77.4%) 24 (66.7%) 72 (69.9%) Current counseling Yes 18 (50%) 18 (58.1%) 19 (52.8%) 55 (53.4%) No 15 (41.7%) 13 (41.9%) 17 (47.2%) 45 (43.7%) Is helpful 17 (47.2%) 15 (48.4%) 17 (47.2%) 49 (89.1%) Note. N =103. ADHD-C = Attention Deficit Hyperactivity Disorder-Combined Type; ADHD- C/ODD = Attention Deficit Hyperactivity Disorder-Combined Type and Oppositional Defiant Disorder; ADHD-C/MDD = Attention Deficit Hyperactivity Disorder-Combined Type and Major Depressive Disorder; GERD = Gastroesophageal Reflux Disease; Anxiety NOS = Anxiety Not Otherwise Specified; PTSD = Posttraumatic Stress Disorder; GAD = Generalized Anxiety Disorder; OCD = Obsessive Compulsive Disorder.

Empathy and Parental Acceptance-Rejection

The sample scores on CE ranged from 10 to 54 (M =29.4, SD = 9.5). The mean score for

EE was 27. 8, SD = 9.1, with a range from 9 to 51. By diagnosis, the ADHD-C group scored M=

30.66, SD = 8.5 for CE and for EE M = 31.8, SD= 7.3. The ADHD-C/ODD group scored the lowest on both CE (M = 28.6, SD = 10.4) and EE (M = 18.7, SD = 5.1), while, the ADHD-

C/MDD group mean scores were M = 28.8, SD = 9.9 for CE and M = 31.6, SD = 7.9 for EE (See

Table 3).

Table 3

Descriptive Statistics of Cognitive and Emotional Empathy Range Variable M SD Min Max Cognitive empathy ADHD-C 30.66 8.47 18 51 ADHD-C/ODD 28.67 10.42 10 54 ADHD-C/MDD 28.80 9.89 10 53 Total 29.41 9.53 10 54

66 Emotional empathy ADHD-C 31.80 7.33 14 51 ADHD-C/ODD 18.77 5.05 9 28 ADHD-C/MDD 31.63 7.96 18 46 Total 27.82 9.13 9 51 Note. N = 103. ADHD-C = Attention Deficit Hyperactivity Disorder-Combined Type; ADHD- C/ODD = Attention Deficit Hyperactivity Disorder-Combined Type and Oppositional Defiant Disorder; ADHD-C/MDD = Attention Deficit Hyperactivity Disorder-Combined Type and Major Depressive Disorder.

The total sample mean score on mother acceptance-rejection was 34.4, SD = 9.7, while the mean score for father acceptance-rejection was 41.4, SD = 15.7. The ADHD-C group scored the lowest on both mother and father acceptance-rejection, M = 33.2, SD = 8.7 and M =37.1, SD

= 13.1, respectively, while the ADHD-C/ODD group scored the highest on both scales, M =

36.3, SD = 11.6 on mother acceptance-rejection and M = 47.1, SD = 16.9 on father acceptance- rejection (See Table 4).

Table 4 Descriptive Statistics of Mother and Father Acceptance-Rejection Range Variable M SD Min Max Mother acceptance-rejection ADHD-C 33.20 8.70 24 53 ADHD-C/ODD 36.33 11.67 24 69 ADHD-C/MDD 34.19 9.12 24 59 Total 34.48 9.79 24 69 Father acceptance-rejection ADHD-C 37.15 13.08 24 79 ADHD-C/ODD 47.18 16.94 25 82 ADHD-C/MDD 41.96 16.40 24 73 Total 41.46 15.70 24 82 Note. n = 101 for mother acceptance-rejection, n = 88 for father acceptance-rejection. ADHD-C = Attention Deficit Hyperactivity Disorder-Combined Type; ADHD-C/ODD = Attention Deficit Hyperactivity Disorder-Combined Type and Oppositional Defiant Disorder; ADHD-C/MDD = Attention Deficit Hyperactivity Disorder-Combined Type and Major Depressive Disorder.

Research Questions

67 Research Question 1: Are there differences in CE based on gender, diagnosis, and the interaction among these two variables?

The results of two-way ANOVA revealed that neither gender, F (1, 97) = 1.05, p = .30, nor the diagnostic group, F (2, 97) = .12, p = .88 had significant effect on CE. Furthermore, the interaction of gender and group was also non-significant, F (2, 97) = 1.01, p = .36. This means that there were no differences in CE between subjects diagnosed with ADHD-C, ADHD-

C/ODD, and ADHD-C/MDD. There were also no differences in CE between male and female subjects. Finally, gender did not moderate the effect of diagnostic group on CE (See Table 5).

Table 5

Two-way ANOVA Summary for Gender, Diagnosis, and Cognitive Empathy Source SS df MS F Corrected model 475.17 5 95.23 1.04 Gender 95.96 1 95.96 1.05 Diagnosis 22.25 2 11.12 .12 Gender x 183.34 2 91.67 1.01 Diagnosis Error 8806.87 97 90.79 Note: R² = .05, adj. R² = .002. *p < .05

Research Question 2: Are there differences in EE based on gender, diagnosis, and the interaction among these two variables?

The two-way ANOVA model was significant, F (5, 97) = 18.96, p < .001. More specifically, the main effect of both gender, F (1, 97) = 5.90, p = .01 and diagnosis, F (2, 97) =

40.71, p < .001 were significant. The interaction of gender and diagnosis was significant as well,

F (2, 97) = 3.97, p = .02. In summary, there were differences in EE between subjects diagnosed with ADHD-C, ADHD-C/ODD and between male and female subjects. Gender also moderated the relationship between EE and diagnosis (See Table 6).

68 Table 6

Two-way ANOVA Summary for Gender, Diagnosis, and Emotional Empathy Source SS df MS F Corrected model 4203.15 5 840.63 18.96*** Gender 261.78 1 261.78 5.91* Diagnosis 3609.80 2 1804.90 40.71*** Gender x Diagnosis 352.19 2 176.09 3.97* Error 4299.70 97 44.32 Note: R² = .49, adj. R² = .46 *p < .05, ***p < .001

Post hoc testing. Post hoc testing was performed to see which specific group(s) was different on EE scores. The interpretation of Bonferroni correction revealed that the ADHD-

C/ODD group’s EE was significantly different; subjects in the ADHD-C/ODD group scored lower than the other two groups (p < .001). There was no significant difference between the

ADHD-C group and the ADHD-C/MDD group (p = .16). Regarding gender effect on EE, males scored significantly lower than females, p = .01; however, since the interaction of gender and diagnosis was significant, the relationship between EE and diagnosis is contingent on gender.

Examining the means of EE for the diagnostic groups, males in the ADHD-C and ADHD-

C/MDD groups scored lower than females on EE; however, this relationship was reversed for the

ADHD-C/ODD group; females in this group scored lower than males (See Table 7).

Table 7

Descriptive Statistics of Emotional Empathy for Diagnostic Groups by Gender Group by Gender M SD n ADHD-C Male 30.45 6.53 31 Female 40.20 7.01 5 ADHD-C/ODD Male 19.30 5.15 23 Female 17.25 4.71 8 ADHD-C/MDD Male 29.58 8.56 17 Female 33.47 7.11 19

69 Note. ADHD-C = Attention Deficit Hyperactivity Disorder-Combined Type; ADHD-C/ODD = Attention Deficit Hyperactivity Disorder-Combined Type and Oppositional Defiant Disorder; ADHD-C/MDD = Attention Deficit Hyperactivity Disorder-Combined Type and Major Depressive Disorder.

Further post hoc testing was performed to investigate whether there were group differences in both of the two subscales (i.e., emotional concern subscale and personal distress subscale) of EE. A two-way ANOVA analysis was performed for each subscale. Both the diagnosis and the interaction of diagnosis with gender were significant for the emotional concern subscale, F (2, 97) = 38.38, p < .001, and F (2, 97) = 3.52, p = .03, respectively. No significant effect was found for gender alone, F (1, 97) = 1.59, p = .21. This means that there were differences in emotional concern between the three groups, ADHD-C, ADHD-C/ODD, and

ADHD-C/MDD and that gender moderated the effect of diagnosis on emotional concern.

However, no differences were found between male and female subjects on emotional concern

(See Table 8).

Table 8

Two-way ANOVA Summary for Gender, Diagnosis, and Emotional Concern Source SS df MS F Corrected model 1452.19 5 290.43 16.80*** Gender 27.52 1 27.52 1.59 Diagnosis 1327.07 2 663.53 38.38*** Gender x Diagnosis 121.69 2 60.84 3.52* Error 4299.70 97 44.32 Note. R² = .49, adj. R² = .46 *p < .05, ***p < .001

Bonferroni correction showed that the mean score of the ADHD-C/ODD group on emotional concern was lower than the other two groups, (p < .001); there were no differences between the ADHD-C and ADHD-C/MDD on this scale (p = 1). The interaction effect of diagnosis with gender showed that emotional concern was higher for females in the ADHD-C

70 and ADHD-C/MDD groups except for ADHD-C/ODD group where females in this group scored significantly lower than their counterpart (See Table 9).

Table 9 Descriptive Statistics of Emotional Concern for Diagnostic Groups by Gender Group by Gender M SD n ADHD-C Male 16.35 4.71 31 Female 21.20 4.43 5 ADHD-C/ODD Male 10.13 3.55 23 Female 8.00 3.11 8 ADHD-C/MDD Male 17.11 4.45 17 Female 18.15 3.84 19 Note. ADHD-C = Attention Deficit Hyperactivity Disorder-Combined Type; ADHD-C/ODD = Attention Deficit Hyperactivity Disorder-Combined Type and Oppositional Defiant Disorder; ADHD-C/MDD = Attention Deficit Hyperactivity Disorder-Combined Type and Major Depressive Disorder.

Post hoc testing was also performed on the personal distress subscale; however, the assumption of homogeneity of variance for two-way ANOVA for this subscale was not met as indicated by a significant Levene’s test (p = .002). Consequently, bootstrap analysis of two-way

ANOVA was conducted to establish confidence in the parameter estimates of this test. The results of the bootstrapping procedure revealed that only the main effect of both gender F (1, 97)

= 5.04, p = .02 and diagnosis, F (2, 97) = 12.36, p < .001 were significant for personal distress.

In other words, there were differences in personal distress between the diagnostic groups and male and female subjects (See Table 10).

Table 10

Two-way ANOVA Summary for Gender, Diagnosis, and Personal Distress Source SS df MS F Corrected model 769.64 5 153.92 6.49*** Gender 119.53 1 119.53 5.04* Diagnosis 586.02 2 293.01 12.36*** Gender x Diagnosis 60.76 2 30.38 1.28

71 Error 2297.85 97 23.68 Note. R² = .25, adj. R² = .21 *p < .05, ***p < .001

Bootstrap procedure for multiple comparisons using Bonferroni correction revealed that the mean score for personal distress for subjects in the ADHD-C/ODD group was significantly lower than the ADHD-C group ( p < .001, 95% CI [-7.21, -3.83]) and the ADHD-C/MDD group

( p < .001, 95% CI [-7.28, -2.50]). Regarding gender, on average, females (M = 14.52, SE = .99,

95% CI [12.86, 15.99]) scored higher than males (M = 11.91, SE = .59, 95% CI [10.72, 13.06]) on personal distress (See Table 11).

Table 11

Descriptive Statistics of Personal Distress for Diagnostic Groups by Gender 95% CI Group by Gender M SE n LL UL ADHD-C Male 14.09 .87 31 12.69 15.44 Female 19.00 2.17 5 16.00 21.66 ADHD-C/ODD Male 9.17 1.01 23 7.95 10.40 Female 9.25 1.72 8 7.40 11.22 ADHD-C/MDD Male 12.47 1.18 17 9.69 15.46 Female 15.31 1.17 19 12.27 18.20 Note. ADHD-C = Attention Deficit Hyperactivity Disorder-Combined Type; ADHD-C/ODD = Attention Deficit Hyperactivity Disorder-Combined Type and Oppositional Defiant Disorder; ADHD-C/MDD = Attention Deficit Hyperactivity Disorder-Combined Type and Major Depressive Disorder.

Research Question 3: To what extent does gender and mother acceptance-rejection moderate the relationship between CE and diagnosis?

A hierarchical multiple regression revealed that at stage one, gender had no significant contribution to the regression model, F (1, 99) = 1.73, p = .19. Diagnosis also was not significant, F (3, 97) = 1.22, p = 30. Introducing the moderator, mother acceptance-rejection in the third stage did not result in significant regression model either and yielded a reduction of R²

72 to zero, F (4, 96) = .91, p = .46. When adding the interaction terms of gender and diagnosis in the fourth stage of the regression model and mother acceptance-rejection interaction with diagnosis in the fifth stage, there was no significant interaction, F (6, 94) = .94, p = .46, and F (8,

92) = .99, p = .44, respectively. Diagnosis and gender were not significant predictors of cognitive empathy. Furthermore, mother acceptance-rejection did not moderate the relationship between diagnosis and cognitive empathy (See Table 12).

Table 12

Hierarchical Regression Analysis of Gender, Diagnosis, and Mother Acceptance-Rejection on Cognitive Empathy Predictor ΔR² β Step 1 .017 Gender Female -.09 Step 2 .019 Diagnosis ADHD-C/ODD - .14 ADHD-C/MDD - .26 Step 3 .00 Mother acceptance-rejection -.06 Step 4 .02 Gender x Diagnosis Female x ADHD-C/ODD .19 Female x ADHD-C/MDD .33 Step 5 .023 Diagnosis x Mother Acceptance- rejection -.03 ADHD-C/ODD x MPARQ .16 ADHD-C/MDD x MPARQ Total R² .08 Note. Gender and diagnosis were dummy coded in which males and ADHD were the reference groups. Constant = 30.89. ADHD-C/ODD = Attention Deficit Hyperactivity Disorder-Combined Type and Oppositional Defiant Disorder; ADHD-C/MDD = Attention Deficit Hyperactivity Disorder-Combined Type and Major Depressive Disorder; MPARQ = Mother Version of Parental Acceptance-Rejection. *p < .05

Research Question 4: To what extent does gender and father acceptance-rejection moderate the relationship between CE and diagnosis?

73 At stage one and two of the regression model, neither gender, F (1, 86) = 1.31, p = .25 nor diagnosis, F (3, 84) = 1.51, p = .21 were significant. The moderator, father acceptance- rejection in the third stage of the model and the interaction of gender and diagnosis in the fourth step did not produce a significant effect on CE, F (4, 83) = 1.13, p = .34, and F (6, 81) = 1.08, p

= .38, respectively. However, introducing the interaction term of father acceptance-rejection with diagnosis in the fifth stage, resulted in an increased R²; the model explained 3% of the variance in CE and a reduction in p value, although the whole model in this stage was also non- significant, F (8, 79) = 1.43, p = .19. A significant effect of the diagnosis ADHD-C/ODD on CE was obtained, β = -.29, t (82) = -2.17, p = .03. Adolescents with ADHD-C/ODD had lower CE on average than males with ADHD-C, but no significance was found for the moderation effect of father acceptance-rejection or gender (See Table 13).

Table 13

Hierarchical Regression Analysis of Gender, Diagnosis, and Father Acceptance-Rejection on Cognitive Empathy Predictor ΔR² β Step 1 .01 Gender Female -.13 Step 2 .03 Diagnosis ADHD-C/ODD - .29* ADHD-C/MDD - .24 Step 3 .00 Father acceptance-rejection .20 Step 4 .02 Gender x Diagnosis Female x ADHD-C/ODD .16 Female x ADHD-C/MDD .31 Step 5 .05 Diagnosis x Father Acceptance-rejection ADHD-C/ODD x FPARQ -.02 ADHD-C/MDD x FPARQ -.31 Total R² .12

74 Note. Gender and diagnostic groups were dummy coded in which males and ADHD-C were the reference groups. Constant = 31.30. ADHD-C/ODD = Attention Deficit Hyperactivity Disorder- Combined Type and Oppositional Defiant Disorder; ADHD-C/MDD = Attention Deficit Hyperactivity Disorder-Combined Type and Major Depressive Disorder; FPARQ = Father Version of Parental Acceptance-Rejection. *p < .05

Post hoc testing. Although the whole regression model for the fantasy subscale of CE was non-significant (F (8, 79) = 1.75, p = .09), findings showed that subjects in the ADHD-

C/ODD group scored .32 units lower than males with ADHD-C for every unit of the fantasy subscale, β = -.32, p = .02. Father acceptance-rejection significantly moderated the relationship between the ADHD-C/MDD and fantasy, β = -.45, p < .01.Subjects in the ADHD-C/MDD group who perceived their father as being more rejecting scored .45 units lower on fantasy than males in the ADHD-C group (See Table 14).

Table 14

Hierarchical Regression Analysis of Gender, Diagnosis, and Father Acceptance-Rejection on Fantasy Predictor ΔR² β Step 1 .00 Gender Female -.21 Step 2 .02 Diagnosis ADHD-C/ODD -.32* ADHD-C/MDD - .19 Step 3 .00 Father acceptance-rejection .37 Step 4 .03 Gender x Diagnosis Female x ADHD-C/ODD .28 Female x ADHD-C/MDD .16 Step 5 .09 Diagnosis x Father Acceptance-rejection ADHD-C/ODD x FPARQ -.10 ADHD-C/MDD x FPARQ -.44** Total R² .06

75 Note. Constant = 17.07. ADHD-C/ODD = Attention Deficit Hyperactivity Disorder-Combined Type and Oppositional Defiant Disorder; ADHD-C/MDD = Attention Deficit Hyperactivity Disorder-Combined Type and Major Depressive Disorder; FPARQ = Father Version of Parental Acceptance-Rejection. *p < .05, **p < .01

The whole regression model for the perspective taking subscale of CE was non- significant, F (8, 79) = 1.14, p = .34. More specifically, diagnosis was not a significant predictor of perspective taking (F (2, 84) = 1.73, p = .166), neither was the interaction of gender with this variable (F (6, 81) = 1.48, p = .19). Gender and father acceptance-rejection did not moderate the relationship between perspective taking and diagnosis either, F (1, 86) = 3.12, p = .08 and F (4,

83) = 1.39, p = .24, respectively (See Table 15).

Table 15

Hierarchical Regression Analysis of Gender, Diagnosis, and Father Acceptance-Rejection on Perspective Taking Predictor ΔR² β Step 1 .03 Gender Female .03 Step 2 .02 Diagnosis ADHD-C/ODD -.12 ADHD-C/MDD - .18 Step 3 .00 Father acceptance-rejection -.08 Step 4 .03 Gender x Diagnosis Female x ADHD-C/ODD -.05 Female x ADHD-C/MDD .31 Step 5 .00 Diagnosis x Father Acceptance-rejection ADHD-C/ODD x FPARQ .08 ADHD-C/MDD x FPARQ -.007 Total R² .01 Note. Constant = 14.22. ADHD-C/ODD = Attention Deficit Hyperactivity Disorder-Combined Type and Oppositional Defiant Disorder; ADHD-C/MDD = Attention Deficit Hyperactivity Disorder-Combined Type and Major Depressive Disorder; FPARQ = Father Version of Parental Acceptance-Rejection.

76 *p < .05

Research Question 5: To what extent does gender and mother acceptance-rejection moderate the relationship between EE and diagnosis?

The whole regression model was significant and explained a total of 44% of the variance in EE (R² = .44, F (8, 92) = 10.97, p < .001). In the first step, gender had a significant effect on

EE and explained 4% of its variance (R² = .4, F (1, 99) = 5.79, p = .01), however, diagnosis explained the largest amount of variation (43%) of EE, F (3, 97) = 26.29, p < .001. Mother acceptance-rejection did not have a significant effect on EE and did not significantly moderate the effect of diagnosis on EE, F (4, 96) = 19.73, p = .48, F (8, 92) = 10.97, p = .59, respectively.

These findings indicate that gender and diagnosis had a significant effect on EE, and that gender significantly moderated the effect of diagnosis on emotional empathy. Although females in general scored higher on emotional empathy than males with ADHD-C, the ADHD-C/ODD group and the females of this group scored lower than the aforementioned counterpart. More specifically, females in general scored .50 units higher on EE than males with ADHD for each unit of this variable, β = .50, p = .004, 95% CI [3.7, 16.61]. The ADHD-C/ODD group and the females in this group scored .57 and .28 units respectively lower on EE than males with ADHD for each unit of EE, β = -.57, p = .001, 95% CI [-14.38, -7.98] and β = -.28, p = .01, 95% CI [-

19.04, -2.41], respectively (See Table 16).

Table 16

Hierarchical Regression Analysis of Gender, Diagnosis, and Mother Acceptance-Rejection on Emotional Empathy Predictor ΔR² β b 95% CI Step 1 .05 Gender Female .50** 9.75 [3.78, 16.61] Step 2 .39 Diagnosis

77 ADHD-C/ODD -.57** -11.23 [-14.38, -7.98] ADHD-C/MDD -.05 -.95 [-5.68, 3.75] Step 3 .00 Mother acceptance-rejection .08 .08 [-.16, .30] Step 4 .03 Gender x Diagnosis Female x ODD -.28* -10.10 [-19.04, -2.41] Female x MDD -.25 -5.94 [-16.06, 2.91] Step 5 .00 Diagnosis x Mother acceptance rejection ADHD-C/ODD x MPARQ -.11 -.16 [-.42, .19] ADHD-C/MDD x MPARQ -.09 -.15 [-.54, .22] Total R² .44 Note. Gender and diagnostic groups were dummy coded. Males and ADHD group were the reference group. Constant = 30.57. ADHD-C/ODD = Attention Deficit Hyperactivity Disorder- Combined Type and Oppositional Defiant Disorder; ADHD-C/MDD = Attention Deficit Hyperactivity Disorder-Combined Type and Major Depressive Disorder; MPARQ = Mother Version of Parental Acceptance-Rejection. *p < .05, **p < .01

Post hoc testing. In addition to the ADHD-C/ODD diagnosis, gender and the interaction of these two variables had a significant effect on emotional concern. Mother acceptance- rejection significantly moderated the relationship between the ADHD-C/MDD and emotional concern, β = -.20, p = .04, 95% CI [-.42, -.01]. Although a decrease in mother rejection showed an increase in emotional concern in the ADHD-C/MDD group, adolescents in the ADHD-

C/MDD group who scored one point higher on mother rejection still had higher emotional concern than males with ADHD-C with mean scores of mother acceptance-rejection (See Table

17).

Table 17

Hierarchical Regression Analysis of Gender, Diagnosis, and Mother Acceptance-Rejection on Emotional Concern Predictor ΔR² β b 95% CI Step 1 .02 Gender Female .40* 4.79 [1.08, 9.27] Step 2 .39

78 Diagnosis ADHD-C/ODD -.53** -6.41 [-8.64, -4.13] ADHD-C/MDD .05 .59 [-1.83, 2.97] Step 3 .00 Mother acceptance-rejection .17 .09 [-.06, .25] Step 4 .03 Gender x Diagnosis Female x ODD -.28* -6.06 [-12.21, -1.28] Female x MDD -.27 -3.88 [-9.96, 1.20] Step 5 .02 Diagnosis x Mother acceptance rejection ADHD-C/ODD x MPARQ -.16 -.14 [-.34, .15] ADHD-C/MDD x MPARQ -.20* -.21 [-.42, -.01] Total R² .42 Note. Gender and diagnosis were dummy coded. Males and ADHD-C were the reference group. Constant = 16.55. ADHD-C/ODD = Attention Deficit Hyperactivity Disorder-Combined Type and Oppositional Defiant Disorder; ADHD-C/MDD = Attention Deficit Hyperactivity Disorder- Combined Type and Major Depressive Disorder; MPARQ = Mother Version of Parental Acceptance-Rejection. *p < .05, **p < .01

Gender (F (1, 99) = 5.12, p = .02), and ADHD-C/ODD diagnosis (F (3, 97) = 9.46, p

<.001) had a significant effect on personal distress subscale of EE, explaining 17% of variance in personal distress, R² = .17. Females scored .24 units higher on personal distress than males with

ADHD-C (β = .42, p < .01, 95% CI [1.95, 8.18]) and the ADHD-C/ODD group scored .40 units lower on this subscale compared to the reference group for each unit of personal distress (β = -

.40, p = .001, 95% CI [-6.62, -2.98]). Mother acceptance-rejection and gender did not moderate the relationship between personal distress and diagnosis (See Table 18).

Table 18

Hierarchical Regression Analysis of Gender, Diagnosis, and Mother Acceptance-Rejection on Personal Distress Predictor ΔR² β b 95% CI Step 1 .04 Gender Female .42** 4.96 [1.95, 8.18] Step 2 .17 Diagnosis

79 ADHD-C/ODD -.40** -4.82 [-6.62, -2.98] ADHD-C/MDD -.13 -1.55 [-4.88, 1.94] Step 3 .00 Mother acceptance-rejection -.02 -.01 [-.16, .14] Step 4 .01 Gender x Diagnosis Female x ODD -.18 -4.03 [-7.73, .06] Female x MDD -.14 -2.06 [-7.28, 2.71] Step 5 .00 Diagnosis x Mother acceptance rejection ADHD-C/ODD x MPARQ -.02 -.02 [-.19, .13] ADHD-C/MDD x MPARQ .05 .05 [-.20, .31] Total R² .17 Note. Gender and diagnosis were dummy coded. Males and ADHD-C were the reference group. Constant = 14.01. ADHD-C/ODD = Attention Deficit Hyperactivity Disorder-Combined Type and Oppositional Defiant Disorder; ADHD-C/MDD = Attention Deficit Hyperactivity Disorder- Combined Type and Major Depressive Disorder; MPARQ = Mother Version of Parental Acceptance-Rejection. **p < .01

Research Question 6: To what extent does gender and father acceptance-rejection moderate the relationship between EE and diagnosis?

The whole regression model was significant and explained 43% of the variance in EE, R²

= .43, F (8, 79) = 9.35, p <.00. Gender, ADHD-C/ODD diagnosis, and the interaction of these two variables had a significant effect on EE. The ADHD-C/ODD group (β = -.57, p = .001, 95%

CI [-15.29, -8.03]) and the females in this group (β = .52, p = .005, 95% CI [2.45 – 19.73]) scored significantly lower on EE than males with ADHD-C. On the other hand, females in general (β = -.29, p = .03, 95% CI [-20.70 – -1.06]), scored higher on EE than the reference group just mentioned above. Father acceptance-rejection did not moderate the relationship between EE and diagnosis (See Table 19).

Table 19

Hierarchical Regression Analysis of Gender, Diagnosis, and Father acceptance-Rejection on Emotional Empathy Predictor ΔR² β b 95% CI Step 1 .05

80 Gender Female .52** 9.74 [2.45, 19.75] Step 2 .40 Diagnosis ADHD-C/ODD -.57** -11.65 [-15.29, -8.03] ADHD-C/MDD -.09 -1.62 [-6.13, 3.18] Step 3 .00 Father acceptance-rejection -.10 -.05 [-.27, .10] Step 4 .02 Gender x Diagnosis Female x ODD -.29* -10.27 [-20.70, -1.06] Female x MDD -.23 -5.04 [-14.73, 3.53] Step 5 .00 Diagnosis x Father acceptance rejection ADHD-C/ODD x FPARQ .08 .08 [-.12, .35] ADHD-C/MDD x FPARQ .06 .05 [-.19, .36]

Total R² .43 Note. Gender and diagnosis were dummy coded. Males and ADHD-C were the reference group. Constant = 29.69. ADHD-C/ODD = Attention Deficit Hyperactivity Disorder-Combined Type and Oppositional Defiant Disorder; ADHD-C/MDD = Attention Deficit Hyperactivity Disorder- Combined Type and Major Depressive Disorder; FPARQ = Father Version of Parental Acceptance-Rejection. *p < .05, **p < .01

Post hoc testing. The whole regression model was significant and explained 46% of the variation in emotional concern subscale of EE (R² = .46, F (8, 79) = 10.49, p < .001). Gender,

ADHD-C/ODD and the interaction of these two variables had a significant effect on emotional concern. Female subjects scored higher than male subjects with ADHD-C by .43 units for each unit of emotional concern, β = .43, p = .04, 95% CI [.37, 11.53]. The ADHD-C/ODD group and females in this group scored .55 and .28, respectively, lower on emotional concern than male subjects with ADHD-C, β = -.55, p = .001, 95% CI [-9.16, -4.67] and β = -.28, p = .04, 95% CI [-

13.66, -.41], respectively (See Table 20).

Table 20

Hierarchical Regression Analysis of Gender, Diagnosis, and Father Acceptance-Rejection on Emotional Concern Predictor ΔR² β b 95% CI

81 Step 1 .03 Gender Female .43* 5.14 [.37, 11.53] Step 2 .39 Diagnosis ADHD-C/ODD -.55** -7.07 [-9.16, -4.67] ADHD-C/MDD .12 1.35 [-1.26, 4.43] Step 3 .01 Father acceptance-rejection -.08 -.02 [-.16, .09] Step 4 .02 Gender x Diagnosis Female x ODD -.28* -6.29 [-13.66, -.41] Female x MDD -.33 -4.58 [-11.69, .83] Step 5 .05 Diagnosis x Father acceptance rejection ADHD-C/ODD x FPARQ .16 .10 [-.04, .26] ADHD-C/MDD x FPARQ -.16 -.09 [-.24, .07]

Total R² .46 Note. Gender and diagnosis were dummy coded. Males and ADHD-C were the reference group. Constant = 15.94. ADHD-C/ODD = Attention Deficit Hyperactivity Disorder-Combined Type and Oppositional Defiant Disorder; ADHD-C/MDD = Attention Deficit Hyperactivity Disorder- Combined Type and Major Depressive Disorder; FPARQ = Father Version of Parental Acceptance-Rejection. *p < .05, **p < .01

Only two predictors were significant for the personal distress subscale; these were the

ADHD-C/ODD diagnosis and gender, but not the interaction of these two variables. The

ADHD/ODD group scored .37 units lower on personal distress than male subjects with ADHD

(β = -.37, p = .002, 95% CI [-6.77, -2.10]) and female subjects had higher personal distress scores than the reference group (β = .17, p = .009, 95% CI [1.26, 8.39]). Father acceptance- rejection did not moderate the effect of diagnosis on personal distress. The whole regression model explained 21% of variance in personal distress (R² = .21, F (8, 79) = 4.05, p <.001) (See

Table 21).

Table 21

Hierarchical Regression Analysis of Gender, Diagnosis, and Father acceptance-Rejection on Personal Distress

82 Predictor ΔR² β b 95% CI Step 1 .03 Gender Female .40** 4.60 [1.26, 8.39] Step 2 .17 Diagnosis ADHD-C/ODD -.37** -4.57 [-6.77, -2.10] ADHD-C/MDD -.27 -2.97 [-5.85, .14] Step 3 .00 Father acceptance-rejection -.08 -.02 [-.20, .09] Step 4 .02 Gender x Diagnosis Female x ODD -.19 -3.97 [-9.32, .92] Female x MDD -.03 -.45 [-6.34, 4.74] Step 5 .05 Diagnosis x Father acceptance rejection ADHD-C/ODD x FPARQ -.03 -.02 [-.17, .16] ADHD-C/MDD x FPARQ .27 .14 [-.02, .34]

Total R² .21 Note. Gender and diagnosis were dummy coded. Males and ADHD-C were the reference group. Constant = 13.74. ADHD-C/ODD = Attention Deficit Hyperactivity Disorder-Combined Type and Oppositional Defiant Disorder; ADHD-C/MDD = Attention Deficit Hyperactivity Disorder- Combined Type and Major Depressive Disorder; FPARQ = Father Version of Parental Acceptance-Rejection. **p < .01

83

Chapter 5

DISCUSSION

84 This study examined the effects of gender, diagnosis of ADHD and comorbidities of

ODD and MDD, and parental acceptance-rejection on CE and EE. The aims of this study were to: (a) examine the main and interaction effect of gender and diagnosis of ADHD-C and comorbidities of ODD and MDD on CE; (b) examine the main and interaction effect of gender and diagnosis of ADHD-C and comorbidities of ODD and MDD on EE; (c) determine whether gender and mother acceptance-rejection moderates the effect of diagnosis on CD; (d) determine whether gender and father acceptance-rejection moderates the effect of diagnosis the CE; (e) determine whether gender and mother acceptance-rejection moderates the effect of diagnosis on

EE; and (f) determine whether gender and father acceptance-rejection moderates the effect of diagnosis on EE.

In this study, the three groups, ADHD-C, ADHD-C/ODD, and ADHD-C/MDD were comparable regarding subjects’ clinical and demographic characteristics except for gender. The majority of subjects in the ADHD-C/MDD group were female, while male subjects composed more than 66% of the sample in the other two groups. On average, the ADHD-C scored the highest on CE while ADHD-C/ODD scored the lowest on EE. The mean scores for ADHD-C and ADHD/MDD on EE were comparable. On average, subjects in the ADHD-C/ODD had the highest scores on both mother and father acceptance-rejection, meaning that subjects in this group perceived their parents as more rejecting of them than the other two groups.

The findings of this study show that male and female subjects were similar in CE. In contrast, female participants had higher EE except for those in the ADHD-C/ODD group; females diagnosed with ADHD-C/ODD had lower EE than males in the other two groups (i.e.,

ADHD/C and ADHD-C/MDD). Interestingly, the effect of gender differed on the two subscales of EE (i.e., emotional concern and personal distress). In the two-way ANOVA model, female

85 subjects did not differ from males in their emotional concern; however, in the regression models, females had higher emotional concern than males. The difference in the findings between the two statistical models may be attributed to the fact that regression analysis estimates the significance of a variable on an outcome after controlling for the effect of other variables including the interaction term, while factorial ANOVA does not control for the effect of the interaction (Olse, 1996). More specifically, factorial ANOVA did not control for the low scores of emotional concern for females in the ADHD-C/ODD and hence resulted in non-significant gender differences on emotional concern. Therefore, estimates from the regression model can be more reliable than those of factorial ANOVA. Both the factorial ANOVA and regression models were congruent in showing that female subjects in the ADHD-C/ODD group scored lower on emotional concern than males. Regarding personal distress subscale of EE, females showed higher personal distress than male subjects.

Subjects in the ADHD-C group and those in the ADHD-C/ODD and ADHD-C/MDD were similar in their CE, but different in their ability to emotionally empathize with others (i.e.,

EE). Subjects in the ADHD-C/ODD group had lower EE than the other two groups. They were lower on their emotional concern towards others and had lower personal distress than subjects in the ADHD-C and ADHD-C/MDD groups.

The moderation effect of parental acceptance-rejection occurred in two instances.

Subjects diagnosed with ADHD with the MDD comorbidity and perceived their father as being more rejecting than those of the ADHD-C group were lower on their ability to fantasize. On the other hand, their perceptions of their mother affected their emotional concern towards others.

Subjects with MDD comorbidity who perceived their mother as rejecting of them showed lower emotional concern towards others, although on average they scored higher than the ADHD-C

86 group on emotional concern. The perceptions of subjects with MDD comorbidity of their father affected their CE, but their perceptions of their mother contributed to their ability to show emotional concern towards others.

Our findings are congruent with those studies regarding females being more empathic than men on scales of EE only (Derntl et al., 2010; Mestre et al., 2009; Rueckert et al., 2011).

Females were also found to have higher scores on EE than men on the two dimensions of EE of the IRI instrument - emotional concern and personal distress (Davis, 1983; De Corter et al.,

2007; Hawk et al., 2013). These findings are consistent with prevalent social stereotypes that females are being more emotional, interdependent, and concerned about others’ feelings than males (Hawk, 2013; Marton et al, 2009). However, there exists some support in the literature that gender differences in empathy can also be related to differences in brain structure between men and women especially regarding EE. In a study of Schulter-Ruther, Markowitsch, Shah, Fink, and Piefke (2008) females were found to be more concerned with others’ feelings than males as the activity of the inferior frontal cortex, which hosts the mirror neuronal system responsible for evoking empathy, was higher among females than males. It is difficult to draw conclusions about the relationship between ADHD and empathy from these findings because only two studies investigated gender differences related to empathy in the ADHD population, and only CE was measured (i.e., Clark et al., 1999; Marton et al., 2009). In contrast to findings from the Clark et al. (1999) and Marton el at. (2009) studies that revealed females scored higher than males on CE, our findings showed no gender differences in CE. Such discrepancies may be related to methodological differences. In the study of Clark et al (1999), parents filled out the questionnaire and CE was assessed using only one question. Marton et al (2009) controlled for language abilities and intelligence and therefore had a stronger design as it has been suggested that

87 language and intelligence are related to CE (Cervantes & Callanan, 1998; Marton et al., 2009).

Although we excluded subjects with a diagnosis of mental retardation, we failed to control for these extraneous variables. Some experts (Da Fonseca et al., 2009) maintain that poor performance of subjects with ADHD on emotion recognition and understanding is unrelated to overall IQ scores.

Other studies also found no gender difference in CE (e.g., Horgan & Smith, 2006; Klein

& Hodges, 2001), which may suggest that females are in fact similar to males in CE. It has been suggested that higher CE scores in females might be driven by motivation to be more empathic especially if they had prior knowledge about the purpose of the empathy task (Klein & Hodges,

2001). If our female subjects were driven to provide responses in line with the prevailing gender stereotypes, they would have scored higher on both dimensions of empathy (i.e., CE and EE), especially on self-report measure as this type of measurement is considered to evoke social bias

(Eisenberg & Lennon, 1983; Hawk et al., 2013; Marton et al., 2009).

Our findings indicate that comorbidity of ODD was negatively related to EE. Subjects diagnosed with ADHD and comorbid ODD scored the lowest on the two subscales of EE (i.e., emotional concern and personal distress). These findings are consistent with research on empathy in the disruptive behavior disorders (DBD) population (e.g., Deschapms et al., 2015; de

Wied et al., 2009; de Wied et al., 2006). Individuals with DBD have been found to have low EE on both physiologic and self-report measures. Therefore, it appears that ODD comorbidity intensifies empathic difficulties in the ADHD population, particularity difficulties related to EE.

It is worth mentioning that our study is among the first to explore the relationship between ODD diagnosis and empathy separately from conduct disorder (CD). Studying ODD diagnosis independent from CD is important for several reasons. First, studies on empathy in the DBD

88 population focused mainly on the effect of CD on empathic difficulties; the role of ODD diagnosis was marginal. Explanations for deficits EE in CD have been widely reported and supported; however, it was unclear whether similar deficits of EE exist among subjects with

ODD. Although longitudinal studies show that ODD symptoms are associated with CD symptoms over time, not all children with ODD develop CD and many may go on to develop internalizing disorders instead (Loeber, Burke, & Pardini, 2009). Finally, the high prevalence of

ODD without CD in subjects diagnosed with ADHD necessitated an exploration of the role of this disorder on social difficulties experienced in adolescents with ADHD, which includes empathy.

Researchers that explored the relationship between DBD and empathy proposed that EE deficit was related to the existence of callous unemotional traits among these subjects, more specifically among individuals with CD. Callous unemotional traits are those characterized by lack of and concern toward others as well as the callous use of others for one’s own gain (Frick & Ellis, 1999; Frick & White, 2008). These traits are found to be associated with the development of psychopathology and antisocial personality behavior in adulthood (Frick &

White, 2008). Kolko and Pardini (2010) pointed out that callous unemotional traits may also exist in children with ODD; however, such linkages are still weak and not well-established.

Future studies need to investigate callous unemotional traits in individuals with ODD and the role they play in empathic deficits among this population, especially EE.

Deschapms et al. (2015) explained that behavioral manifestations of DBD including defiance, disruptive behavior, and aggression underlie poor EE. They added that aggression is found to be related inversely with empathy and that empathy results in the inhibition of aggressive behavior. In turn, displaying emotional concern towards others’ distress can evoke

89 sympathy, which may inhibit aggression and hence the relationship between empathy and aggression can be considered bidirectional (Davis, 1996; de Wied et al., 2005; Hoffman, 2000).

Another interpretation is provided by Evans et al (2002) who argued that children with DBD show inhibited EE rather than the lack of ability to emotionally feel for others. They explained that these children tend to misinterpret social cues in a way that are likely to elicit feelings of threat and anger (Evans et al., 2002). They also tend to misperceive the intentions of others as being more hostile and aggressive, which is a typical feature of DBD diagnosis (Evans et al.,

2002; Miller & Eisenberg, 1988).

In light of current literature, it is difficult to interpret our findings of why female subjects in the ADHD-C/ODD group had the lowest scores on EE, particularly on their emotional concern subscale. Research has failed to explore gender differences in empathy in the ODD population. In this study, females in the ADHD-C/ODD group also scored highest on both father and mother acceptance-rejection, which means that they perceived their mother and father as more rejecting than the rest of the sample. Cervantes and Callanan (1998) reported that empathic tendencies are fostered and reinforced in girls more than boys during their socialization and interaction with their parents, especially their mother. Mothers who engage in emotional talk with their daughters are much better in preparing and orienting them towards interpersonal relationships involving emotional concern and sensitivity (Cervantes & Callanan, 1998; Fuvish,

2008). Another possible explanation is that mother and father rejection increases aggression and externalizing problems among adolescents and aggressive behavior is reported to be negatively related to empathy. Parental rejection was found to be a significant predictor of externalizing behaviors (Shaw et al., 1998) and positively correlated with aggression (Roelofs et al., 2006).

Although our study failed to find a moderation effect of parental acceptance-rejection on

90 empathy in the ADHD-C/ODD group, this may be related to low power in the present study.

Whisman and McCleland (2005) argued that when testing interaction terms, the sample size should be larger than what is actually calculated. For example, they recommended a sample size of more than 200 participants to adequately detect interactions with medium effect sizes using measures with reliabilities of .70. Furthermore, the ADHD/ODD group in our study had the lowest number of subjects compared to the other two groups.

The present study showed that parental acceptance-rejection mediated the relationship between empathy and the diagnosis of ADHD-C/MDD. The adolescents of this group who perceived their father as rejecting of them had lower scores on fantasy subscale of CE, while perceived mother’s rejection affected their emotional concern (i.e., lower emotional concern).

The current literature supports the role of parental warmth on empathy as it has been suggested that warm and supportive parenting is vital in the development of secure parent-adolescent relationships (Garber, Robinson, & Valentiner, 1997; Laible, Carlo, & Roesch, 2004). This secure relationship creates an affective climate at home that fosters the development of empathy and promote prosocial behavior (Garber et al., 1997; Laible et al., 2004; Zahn-Waxler & Radke-

Yarrow, 1990). The specific mechanism in which parental acceptance-rejection affects empathy in adolescents with MDD comorbidity, however, is unclear and lacking in the literature. Some studies suggested that parental rejection and lack of warmth affects the child’s self-esteem

(Garber & Flynn, 2001). When parents lack to show warmth and fail to be sensitive and supportive to their child, the child construct a model of the self as unworthy and undeserving of love (i.e., low self-esteem). Therefore, the child will feel less competent to assist others in need because their own needs are not being met (Eisenberg & Faabes, 1998; Yates & Youniss, 1996).

91 Paternal role in CE, specifically father’s contribution to child’s ability to fantasize (i.e., the child’s ability to transpose themselves in imaginative situations) is not-reported in the current literature. We may elicit an interpretation of father’s role in this area based on the available literature of parental influence on a child’s development. Although the majority of studies focused primarily on mothers, Lewis and Lamb (2013) stressed the vital role fathers play in their child’s upbringing. They pointed out that fathers are highly and consistently involved in child’s play versus caretaking; the latter is primarily the mother’s responsibility. Play is recognized to greatly influence child’s imagination and fantasy (Lillard et al., 2013). More importantly, children’s imagination was found to be greatly influenced by their fathers’ story-telling at bedtime. A recent study reported that fathers spark the child’s imaginative discussion during bed- time story reading. While mothers approached this task by asking factual facts, fathers cognitively challenge their children by asking questions that required the use of imagination (The

Telegraph, 2017).

Conclusions on the role of the mother in the development of emotional concern are similar to the above discussion of EE in adolescents with an ODD comorbidity. It seems that mothers who are rejecting of their children are less available and accessible to the child, which in return reduces the mother-child interaction and socialization. Such interaction involves emotional talk that prepares children to be sensitive and emotionally concerned about others’ feelings (Cervantes & Callanan, 1998; Fivush, McDermott, & Bohanek, 2008). Although mother rejection resulted in lower emotional concern among subjects with ADHD-C/MDD, they still scored higher on emotional concern than subjects with ADHD-C. It has been reported that subjects diagnosed with MDD attribute self-blame and for others’ distress and thus leads them to manifest withdrawal and avoidance behavior from empathy-inducing behaviors (Batson,

92 2009; O’ Connor, Berry, Lewis, & Stiver, 2012; O’Connor et al., 2007; O’Connor et al., 2002;

Zahn-Waxler & Van Hulle, 2012). Such explanations are in line with the empathy imbalance hypothesis that guided this study. This theory proposed that in intense empathy-eliciting situations, especially those involving negative feelings, individuals may withdraw from such situations to avoid personal distress (Smith, 2009).

Limitations

There are several limitations in this study. First, the use of convenience sampling method may limit the representativeness and hence the generalizability of findings. For example, the majority of participants were Caucasians and males were predominant in two groups (i.e.,

ADHD-C and ADHD-C/ODD). The use of convenience sampling also did not allow matching the groups on some demographic characteristics such gender. Limiting recruitment of subjects and data collection from two settings in Northeast Ohio also restrict generalizability.

Another limitation is the relative small sample size and this could have affected the significance and magnitude of the relationships between the proposed variables. As we mentioned earlier, Whisman and McCleland (2005) suggested that for studies testing moderation effect, a sample size of 200 subjects may be required for medium effect size and measures of at least .70 of reliability. A practical constraint was the difficulty in ensuring equal number of subjects in each group, which is considered another limitation in this study. Equal sample size in each group is of relative importance to various ANOVA analyses. Although in this study the

ADHD-C/ODD group was lower by five subjects than the other two groups, this may affected the significance and the magnitude of the main effect of the variables in factorial ANOVA

(Field, 2013). Another shortcoming of this study is the lack of control group that limited the ability to compare empathic responses of the study groups to the general population.

93 This study relied on self-report measure of empathy using the IRI. It has been suggested that self-report measure have the tendency to elicit social desirability bias. Self-report measures of empathy may evoke demand characteristics; when subjects become aware that empathy is being assessed, they may provide responses relevant with common gender stereotypes

(Eisenberg & Lennon, 1983; Marton et al., 2009). Relying solely on one self-report measure for assessing empathy is considered another shortcoming of this study.

Subjects’ diagnosis of ADHD and its comorbidities of ODD and MDD were obtained from their medical record as documented by their mental health provider. This study was unable to verify these diagnoses using available and valid assessment tools. Such shortcoming may pose a threat to the internal validity of the study. The ability to assess and verify subjects’ diagnosis would have given us more confidence in drawing conclusions about the relationship of diagnosis and empathy.

Implications for Nursing Research and Practice

This study is the first to compare CE and EE in adolescents diagnosed with ADHD and

ODD and MDD comorbidities. Future research is needed to further investigate empathic responses amongst adolescents with these diagnoses. Such investigation requires: (a) the use of adequate and equal sample size among the groups; (b) matching subjects on important demographic data such as gender; (c) the use of more than one measure in assessing empathy, including more objective measures; (d) verifying subjects’ diagnoses using reliable and valid assessment tools, and (d) the inclusion of a control group. Gender difference in empathy is well- established in the literature; however, the majority of studies of empathy in subjects with ADHD,

ODD, and MDD failed to account for or investigate gender difference. Therefore, this should be an area of consideration for future research. It also needs to explore possible etiologies that

94 account for empathic deficits in ADHD, ODD, and MDD since the focus on this area is still deficient and probabilistic.

This study also drew attention to the role of parenting on empathy in subjects with

ADHD and those with ADHD and ODD and MDD comorbidities by investigating the effect of parental acceptance-rejection. Current research is lacking in this area and is mainly concerned with the role of parental acceptance-rejection on the behavioral manifestations of specific psychiatric diagnoses (e.g., Lifford et al., 2008; Shaw et al., 1998). Studying the mechanisms or pathways of the effect of specific components of parenting on empathy in subjects with ADHD and ADHD with common comorbidities is of great importance as well.

The findings of this study can inform nursing practice. Empathy plays a major role in adolescents’ socialization and promotes healthy interpersonal relationships (e.g., Hay, Hudson,

& Liang, 2010; Hoza et al., 2003; Ollendick et al., 1992). Mental health nurses and other health care practitioners need to consider the importance and role of empathy in the well-being of social development for adolescents diagnosed with ADHD. They also need to pay attention to the role of frequent common ADHD comorbidities in this population and how these affect interpersonal relations, including those concerning empathy. Our study found that adolescents diagnosed with

ADHD and ODD had more intense difficulties with EE, especially among females. It also showed that adolescents who had a diagnosis of ADHD with MDD comorbidity had higher emotional concern than those with the other ADHD diagnoses. Therefore, taking comorbidities of ADHD into account when designing and delivering interventions for this population to promote their empathic responses is important. Such interventions need to be tailored according to gender and the specific empathic deficit for each population. It may be of huge importance to first include empathic teaching within the scope of intervention planning and implementation for

95 the ADHD population. The mainstream of psychotherapy has focused on teaching primary social skills that target the main symptoms of ADHD (i.e., inattention, hyperactivity, and impulsivity); interventions designed to improve EE and CE can be easily incorporated in psychotherapy sessions (Spiro, 1992).

Findings in this study show the importance of parental acceptance-rejection on empathy, especially for subjects with ADHD-C diagnosis with MDD. Perceived paternal rejection affected

CE in this group, particularly, their ability to fantasize, while maternal rejection reduced their ability to feel for others. Mental health personnel need to assess how subjects with ADHD especially with MDD comorbidity perceive their parents and the quality of parent-child relationship. Parents need also to be a target of empathy-related interventions. Educating parents on the important role they play in their child’s ability to empathize is a first step. Planning and delivering interventions to promote the quality of parent-child relationship can be another area of focus for mental health nurses.

96 Appendix A Interpersonal Reactivity Index (IRI) Instrument

The following statements inquire about your thoughts and feelings in a variety of situations. For each item, indicate how well it describes you by choosing the appropriate letter on the scale at the top of the page: A, B, C, D, or E. When you have decided on your answer, put an X next to the letter that best describes you for each statement. READ EACH ITEM CAREFULLY BEFORE RESPONDING. Answer as honestly as you can. Thank you.

ANSWER SCALE:

A B C D E

DOES NOT DESCRIBES ME DESCRIBE ME VERY WELL WELL

A B C D E Statement Doesn’t Describes Describe Me Very Me Well Well 1. I daydream and fantasize, with some regularity, about things that might happen to me.

2. I often have tender, concerned feelings for people less fortunate than me.

3. I sometimes find it difficult to see things from the "other guy's" point of view.

4. Sometimes I don't feel very sorry for other people when they are having problems.

5. I really get involved with the feelings of the characters in a novel.

97

A B C D E Statement Doesn’t Describes Describe Me Very Me Well Well 6. In emergency situations, I feel apprehensive and ill-at-ease.

7. I am usually objective when I watch a movie or play, and I don't often get completely caught up in it.

8. I try to look at everybody's side of a disagreement before I make a decision.

9. When I see someone being taken advantage of, I feel kind of protective towards them.

10. I sometimes feel helpless when I am in the middle of a very emotional situation.

11. I sometimes try to understand my friends better by imagining how things look from their perspective.

12. Becoming extremely involved in a good book or movie is somewhat rare for me.

13. When I see someone get hurt, I tend to remain calm.

14. Other people's misfortunes do not usually disturb me a great deal.

15. If I'm sure I'm right about something, I don't waste much time listening to other people's arguments.

16. After seeing a play or movie, I have felt as though I were one of the characters.

98

A B C D E Statement Doesn’t Describes Describe Me Very Me Well Well 17. Being in a tense emotional situation scares me.

18. When I see someone being treated unfairly, I sometimes don't feel very much for them.

19. I am usually pretty effective in dealing with emergencies

20. I am often quite touched by things that I see happen.

21. I believe that there are two sides to every question and try to look at them both. 22. I would describe myself as a pretty soft-hearted person.

23. When I watch a good movie, I can very easily put myself in the place of a leading character.

24. I tend to lose control during emergencies

25. When I'm upset at someone, I usually try to "put myself in his shoes" for a while.

26. When I am reading an interesting story or novel, I imagine how I would feel if the events in the story were happening to me.

27. When I see someone who badly needs help in an emergency, I go to pieces.

28. Before criticizing somebody, I try to imagine how I would feel if I were in their place.

99 Appendix B

Mother Version of Parental Acceptance Rejection Questionnaire- Child Version (Short-Form)

The following pages contain a number of statements describing the way mothers sometimes act toward their children. I want you to think about how each one of these fits the way your mother treats you.

Four boxes are drawn after each sentence. If the statement is basically true about the way your mother treats you then ask yourself, “Is it almost always true?” or “Is it only sometimes true?” If you think your mother almost always treats you that way, put an X in the box ALMOST ALWAYS TRUE; if the statement is sometimes true about the way your mother treats you then mark SOMETIMES TRUE.

If you feel the statement is basically untrue about the way your mother treats you then ask yourself, “Is it rarely true?” or “Is it almost never true?” If it is rarely true about the way your mother treats you put an X in the box RARELY TRUE; if you feel the statement is almost never true then mark ALMOST NEVER TRUE.

Remember, there is no right or wrong answer to any statement, so be as honest as you can. Respond to each statement the way you feel your mother really is rather than the way you might like her to be. For example, if she almost always hugs and kisses you when you are good, you should mark the item as follows:

MY MOTHER TRUE OF MY NOT TRUE OF MY MOTHER MOTHER

Almost Sometimes Rarely Almost Always True True Never True True

Hugs and kisses me when I am good x ☐ ☐ ☐

100

MY MOTHER TRUE OF MY NOT TRUE OF MY MOTHER MOTHER

Almost Sometimes Rarely Almost Always True True Never True True

1. Says nice things about me ☐ ☐ ☐ ☐

2. Pays no attention to me ☐ ☐ ☐ ☐

3. Makes it easy for me to tell her things that ☐ ☐ ☐ ☐ are important to me

4. Hits me, even when I don’t deserve it ☐ ☐ ☐ ☐

5. Sees me as a big nuisance ☐ ☐ ☐ ☐

6. Punishes me severely when she is angry ☐ ☐ ☐ ☐

7. Is too busy to answer my questions ☐ ☐ ☐ ☐

8. Seems to dislike me ☐ ☐ ☐ ☐

9. Is really interested in what I do ☐ ☐ ☐ ☐

10. Says many unkind things to me ☐ ☐ ☐ ☐

11. Pays no attention when I ask for help ☐ ☐ ☐ ☐

12. Makes me feel wanted and needed ☐ ☐ ☐ ☐

13. Pays a lot of attention to me ☐ ☐ ☐ ☐

14. Goes out of her way to hurt my feelings ☐ ☐ ☐ ☐

15. Forgets important things I think she ☐ ☐ ☐ ☐ should remember

16. Makes me feel unloved if I misbehave ☐ ☐ ☐ ☐

17. Makes me feel what I do is important ☐ ☐ ☐ ☐

101 18. Frightens or threatens me when I do ☐ ☐ ☐ ☐ something wrong

19. Cares about what I think, and likes me to ☐ ☐ ☐ ☐ talk about it

20. Feels other children are better than I am ☐ ☐ ☐ ☐ no matter what I do

21. Lets me know I am not wanted ☐ ☐ ☐ ☐

22. Lets me know she me ☐ ☐ ☐ ☐

23. Pays no attention to me as long as I do ☐ ☐ ☐ ☐ nothing to bother her

24. Treats me gently and with ☐ ☐ ☐ ☐

102

Appendix C

Father Version of Parental Acceptance-Rejection Questionnaire- Child Version (Short-Form)

The following pages contain a number of statements describing the way fathers sometimes act toward their children. I want you to think about how each one of these fits the way your father treats you.

Four boxes are drawn after each sentence. If the statement is basically true about the way your father treats you then ask yourself, “Is it almost always true?” or “Is it only sometimes true?” If you think your father almost always treats you that way, put an X in the box ALMOST ALWAYS TRUE; if the statement is sometimes true about the way your father treats you then mark SOMETIMES TRUE.

If you feel the statement is basically untrue about the way your father treats you then ask yourself, “Is it rarely true?” or “Is it almost never true?” If it is rarely true about the way your father treats you put an X in the box RARELY TRUE; if you feel the statement is almost never true then mark ALMOST NEVER TRUE.

Remember, there is no right or wrong answer to any statement, so be as honest as you can. Respond to each statement the way you feel your father really is rather than the way you might like him to be. For example, if he almost always hugs and kisses you when you are good, you should mark the item as follows:

MY FATHER TRUE OF MY NOT TRUE OF MY FATHER FATHER

Almost Sometimes Rarely Almost Always True True Never True True

Hugs and kisses me when I am good x ☐ ☐ ☐

103

MY FATHER TRUE OF MY NOT TRUE OF MY FATHER FATHER

Almost Sometimes Rarely Almost Always True True Never True True

1. Says nice things about me ☐ ☐ ☐ ☐

2. Pays no attention to me ☐ ☐ ☐ ☐

3. Makes it easy for me to tell him things ☐ ☐ ☐ ☐ that are important to me

4. Hits me, even when I don’t deserve it ☐ ☐ ☐ ☐

5. Sees me as a big nuisance ☐ ☐ ☐ ☐

6. Punishes me severely when he is angry ☐ ☐ ☐ ☐

7. Is too busy to answer my questions ☐ ☐ ☐ ☐

8. Seems to dislike me ☐ ☐ ☐ ☐

9. Is really interested in what I do ☐ ☐ ☐ ☐

10. Says many unkind things to me ☐ ☐ ☐ ☐

11. Pays no attention when I ask for help ☐ ☐ ☐ ☐

12. Makes me feel wanted and needed ☐ ☐ ☐ ☐

13. Pays a lot of attention to me ☐ ☐ ☐ ☐

14. Goes out of his way to hurt my feelings ☐ ☐ ☐ ☐

15. Forgets important things I think he ☐ ☐ ☐ ☐ should remember

16. Makes me feel unloved if I misbehave ☐ ☐ ☐ ☐

17. Makes me feel what I do is important ☐ ☐ ☐ ☐

104

18. Frightens or threatens me when I do ☐ ☐ ☐ ☐ something wrong

19. Cares about what I think, and likes me to ☐ ☐ ☐ ☐ talk about it

20. Feels other children are better than I am ☐ ☐ ☐ ☐ no matter what I do

21. Lets me know I am not wanted ☐ ☐ ☐ ☐

22. Lets me know he loves me ☐ ☐ ☐ ☐

23. Pays no attention to me as long as I do ☐ ☐ ☐ ☐ nothing to bother him

24. Treats me gently and with kindness ☐ ☐ ☐ ☐

105

Appendix D

Demographic and Clinical Data Sheet

1- Sex

1. Male 2-Female

2- Age

1- 12-14

2- 15-16

3- 17-18

3- School Grade ------

4- Race/Ethnicity

1- Caucasian

2- African-American

3- Hispanic

4- Asian

5- American Indian

6- Other, Specify

5-Have you received counseling before? Yes ______No ______If yes, did you find it helpful? Yes ______No ______

6-Are receiving counseling now? Yes ______No ______If yes, do you find it helpful? Yes ______No ______

106

Appendix E

Clinical Data Sheet

Study: Cognitive and Affective Empathy in Adolescents with ADHD: Are Comorbidities and Parental Acceptance-Rejection Important Factors?

Adolescent ID: ______

Age: ______

Sex: ______

Primary Psychiatric Diagnosis: ______

Other Psychiatric Diagnosis: ______

Other Medical Diagnosis:

List of Medication(s) taken: 1- 2- 3- 4- 5-

Counseling received: yes ______no ______

Type of Counseling Received:

______

107

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