ADHD Atten Def Hyp Disord
DOI 10.1007/s12402-015-0187-9
ORIGINAL ARTICLE
Understanding intentionality in children with attention-deficit/
hyperactivity disorder
Azar Mohammadzadeh1,2 • Mehdi Tehrani-Doost1,2 • Anahita Khorrami2
Nahid Noorian2
Received: 15 March 2015 / Accepted: 11 November 2015
Ó Springer-Verlag Wien 2015
Abstract One of the main aspects of theory of mind is
intentionality which refers to recognizing other people’s
intentions in their behaviors. The aim of this study was to
investigate intentionality in children with attention-deficit/
hyperactivity disorder (ADHD). Thirty children with
ADHD were compared to thirty age- and IQ-matched
normal children. All participants were assessed using the
moving shapes paradigm task which contains one large red
and one small blue triangle moving around a black screen.
They were asked to describe what the movements mean
and how the triangles interact with each other. The answers
were rated based on the accuracy, type of descriptions
applied, mental states, and length of phrases. With regard
to intentionality score, children with ADHD performed
significantly worse than normal children (P \ .05). Based
on appropriateness score, the accuracy of patients’ answers
was lower in comparison with the control group. Children
with ADHD used longer phrases as compared to controls.
Children with ADHD can have problems with compre-
hending others’ intentionality. This leads to impairment in
social relationship.
Keywords Theory of mind
Intentionality
Attention-
deficit/hyperactivity disorder (ADHD)
Moving shapes
paradigm
& Mehdi Tehrani-Doost
tehranid@sina.tums.ac.ir
1
Department of Psychiatry, Roozbeh Psychiatry Hospital,
Tehran University of Medical Sciences, South Kargar
Avenue, Tehran 1333715914, Iran
2
Institute for Cognitive Science Studies, Tehran, Iran
•
Introduction
Attention-deficit/hyperactivity disorder (ADHD) is char-
acterized by inattention, impulsivity, and hyperactivity. It
is one of the most common psychiatric disorders of youth
[American Psychiatric Association (APA) 2000] and esti-
mated to affect 5–7 % of school-age children (Polanczyk
and Rohde 2007). Although ADHD symptoms tend to
decline with age, at least 50 % of children with ADHD will
still experience impairing symptoms in adulthood (Faraone
et al. 2006).
ADHD is associated with impairments in cognitive,
academic, and interpersonal functions (Barkley 2003).
Interpersonal problems are manifested as rejection by peers
and conflicts with other children and adults. Social dys-
function may be of crucial importance for prognosis of
children with ADHD (Greene et al. 1997). It was also
mentioned that these children have difficulty with emotion
regulation and inhibition of inappropriate behaviors
(Barkley 2003). Impaired social relationship is present in a
majority of children with ADHD (52–82 %; Nijmeijer
et al. 2008).
A successful social interaction is dependent on our
ability to understand own and others’ mental states and
feelings. The ability to infer people’s mental states in social
situation plays a crucial role in our interpersonal interac-
tions. Theory of mind (ToM) describes the ability to
attribute and understand others’ mental states such as
belief, desire, thought, and intention. This ability enables
us to predict others’ behaviors and explain their actions
based on their intentions (Bruncm and Brunce-Cohrem
2005). One of the main aspects of ToM is understanding
others’ intentions. A substantial body of evidence has
suggested impaired ToM in a variety of neuropsychiatric
disorders, such as autism (Shamay-Tsoory and Aharon-
123

Peretz 2007) and schizophrenia (Koelkebeck et al. 2010).
There are a few studies focused on ToM ability in atten-
tion-deficit/hyperactivity disorder (ADHD).
Despite the fact that children with ADHD have some
problems in their social interaction, little is known about
theory of mind in these patients. Charman et al. (2001)
applied to youth with ADHD and healthy controls the
Happe’s Strange Stories Task. They found no significant
differences between the two groups. Similar results have
been found in Perner et al.’s (2002) and Dyck et al.’s
(2001) studies. These results contrasted with Sodian’s
(2003) and Butielaar’s (1999) in which they reported
impaired performance in children with ADHD while doing
ToM tasks. Notably, all previous studies have investigated
mentalizing ability using different kinds of tasks which
lead to different results. Theory of mind is a general phe-
nomenon that has several components such as belief,
intention, and desire. Different results seen in ToM studies
may be due to different aspects of theory of mind inves-
tigated in these studies. To our knowledge, there is no
study addressing understanding intentionality in these
children. It is hypothesized that interpersonal problems
seen in individuals with ADHD can be attributed to their
impairment in comprehending intentionality. This leads to
inappropriate reaction based on their misinterpretation of
others’ behaviors. Intentionality can be evaluated using the
moving shape paradigm through the social interpretation of
the movements. This paradigm was first developed by
Castelli et al. (2000) to investigate ToM deficits by means
of applying an animation video clip which showed two
moving triangles as socially interacting with each other.
This paradigm was later used by Abell et al. (2000) in order
to evaluate impairment of ToM performance in autistic
disorder. This task was shown to activate the neural ToM
networks in one functional imaging study (Castelli et al.
2002). The paradigm contains high complicated level of
abstraction which discriminates it from other types of
theory of mind tasks (Sprong et al. 2007).
In this study, we aimed to investigate understanding
intentionality in children with ADHD compared to normal
developing children using the movement shape paradigm.
Our hypothesis is that, these children have difficulty in
understanding intentional behaviors.
Methods
Participants
Sixty participants were recruited in this study including
thirty drug naı̈ve children with ADHD age between 7 and 9
(mean = 7.9 years, SD = 0.74), ranging from 7 years
2 months to 8 years 9 months. They were matched by age
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A. Mohammadzadeh et al.
with the control group, 30 typically developing children
(mean = 7.3 years, SD = 0.75) ranging from 7 years
1 month to 9 years 0 months; Table 1).
ADHD group
Thirty boys who were diagnosed with ADHD, combined
type, were enrolled in the study. Since the prevalence of
ADHD in boys is more than in girls and psychological
dysfunctions may be different in two genders (Gaub and
Carlson 1997; Nigg et al. 1999), we selected just boys for
the study.
Children with ADHD were recruited from patients
referred to a clinic of child and adolescent psychiatry. They
were not on any medication. All children were evaluated
based on DSM-IV (APA 1994), criteria by a child and
adolescent psychiatrist. To confirm the diagnosis and
evaluate the severity of ADHD symptoms, the Conners’
Parent Rating Scales—Revised (CPRS-R) was also used.
Exclusion criteria were (1) history of mental retardation,
brain trauma, and neurological disorders based on clinical
interview; (2) physical impairment prevented execution of
ToM tasks; (3) any comorbidity except for oppositional
defiant symptoms or disorder (ODD) because of high
prevalent of comorbidity of these symptoms with ADHD.
Control group
Thirty typically developing boys matched on age with the
patient group were recruited from the main stream primary
schools. They had negative history of any psychiatric or
neurological problems based on interviewing with their
parents and completing CPRS. Individual informed con-
sents were obtained from participants’ parents before
entering the study.
Measures
All participants were evaluated using the revised version of
Conner’s Parent Rating Scale, full version of Wechsler
Intelligence Test (WISC-III) and the moving shapes para-
digm task.
Conners’ Parent Rating Scales—Revised
The short version of Conner’s Parent Rating Scale was
used to confirm the diagnosis and evaluate the severity of
ADHD symptoms. It has four indices, oppositionality,
cognitive problem, hyperactivity, and ADHD index. The
validity of CPRS was evaluated in an Iranian clinical
sample (N = 311) compared to normal children
(N = 321). It was found that this instrument can discrim-
inate children with ADHD from non-affected individuals
Understanding intentionality in children with attention-deficit/hyperactivity disorder

Table 1 Characteristics of the

ADHD (N = 30) Control (N = 30) P
two groups in terms of age, IQ,
and CPRS variables Mean SD Min Max Mean SD Min Max

Age 7.9 0.74 7 9 7.6 0.67 7 9 NS

IQ
Full version IQ 102.42 9.80 87 124 110.52 8.88 91 124 0.000
Verbal IQ 104.42 8.86 91 120 110.21 9.79 96 133 0.03
Performance IQ 99.50 12.18 80 126 103.83 20.89 11 126 NS
CPRS variables
Oppositionality 64.28 19.17 41 88 50.61 7.04 40 64 0.002
Inattention 61.64 21.74 40 86 50.48 6.75 41 66 0.000
Hyperactivity 65.08 18.84 41 90 51 6.02 42 64 0.001
ADHD index 62.80 18.93 42 84 50.82 6.56 40 65 0.000

based on all subscales (P \ 0.001). Mean and standard
deviation of ADHD index in patient group was 25.11 and
6.84, respectively, where as these variables in normal
group was 10.89 and 7.65 (Tehrani-Doost, unpublished).
Moving shapes paradigm task
A series of computerized animations based on moving
shapes paradigm were originally developed by Castelli in
2000 and used in Abell et al. (2000) and Castelli et al.
(2000) studies. Based on the original type, the authors
redesigned it just graphically to better visualize using the
Macromedia Flash 8.0 program (Mohammadzadeh et al.
2012). The animations contained one large red and one
small blue triangle moving around a black screen. There
were two conditions: random with two and ToM with three
trials. Since we wanted to evaluate intentionality, we used
random and ToM animations. In random animations, two
triangles do not interact with each other and just float or
bounce about. In ToM sequences, one character reacts to
other’s mental states such as surprising, coaxing, and
bluffing (Abell et al. 2000). The two conditions last
between 34 and 45 s.
The recorded answers were evaluated by two raters
using the scoring criteria suggested by Castelli et al.
(2000). Answers were categorized into four dimensions
including intentionality, appropriateness, length of phrases,
and emotional words. Intentionality reflects the degree of
attribution of mental states to the animations and is cal-
culated by analyzing the content of each description given
by the subjects. Its score ranges from 0 (non-deliberate
action) to 5 (deliberate action). Appropriateness of
description measures to what extent the event understood
by the subject is appropriate with what is intended by the
examiner (measured by 0–3 points). Length of phrases
describes the number of words and phrases which children
have used in describing the animation (0–4 point). Emo-
tional words score calculates emotional terms (e.g., happy,
sad, and afraid) and behaviors which cannot exist without a
shared emotional state between the characters (cheering,
hugging, and kissing).
Procedure
Each participant was evaluated over two sessions in a quiet
room. Prior to the assessment, children’s parents were
interviewed and then asked to complete the CPRS ques-
tionnaire. To evaluate children’s intelligence quotient, they
were assessed using the Wechsler Intelligence Scale during
the first session. Theory of mind tasks were administered in
second session. Prior the main task, two practice trials were
being shown to children. Children were primarily instruc-
ted to freely explain what they see without any guidance
from the examiner. Then they had to describe the move-
ments in terms of actions, interactions, and mental states
based on the questions offered by the examiner. The chil-
dren’s responses were recorded for further evaluation.
Animations were being presented in a pseudo-random
order.
Statistical analysis
Data was analyzed using the SPSS version 17.0. To
examine the differences between the two groups’ answers
in terms of ToM variables, the analysis of variances
(ANCOVA) was used with verbal IQ as a covariate. The
differences between the two groups in terms of CPRS and
WICS-III variables were also investigated using the anal-
ysis of variances (ANOVA). Furthermore, Pearson corre-
lation coefficient (two-tailed) analyses were conducted for
evaluation of association between ToM variables and
CPRS subscales in ADHD group.

123
 A. Mohammadzadeh et al.

Results Discussion

The analysis showed no significant difference between
the two groups in terms of age [F(1, 58) = 2.49, P =
0.12] and performance IQ [F(1, 58) = .78, P = 0.37].
There were significant differences between the ADHD
group and healthy control with regard to full IQ [F(1,
58) = 10.11, P = 0.003] and verbal IQ scores [F(1,
58) = 4.98, P = 0.03]. However, the correlation analy-
sis between the ToM variables and IQ did not reveal any
significant association. There were also significant dif-
ferences between the two groups in terms of CPRS
variables (P \ 0.01; Table 1).
With regard to ToM task variables, the ANCOVA
method (IQ as a covariate) intentionality score in ADHD
group was significantly lower than the normal group [F(1,
58) = 8.12, P = 0.001]. Moreover, the ‘appropriateness’
scores in normal children were significantly higher as
compared to patient group [F(1, 58) = 8.61, P = 0.001].
In terms of length of phrases, this score was significantly
higher in children with ADHD as compared to the other
group [F(1, 58) = 4.28, P = 0.01]. The number of emo-
tional words used by the two groups was not significantly
different (Table 2). We also conducted ANCOVA, while
the oppositionality was considered as a covariate. The
scores were still significantly worse in children with
ADHD in terms of ‘intentionality’ [F(2, 57) = 5.76,
P = 0.005], ‘appropriateness’ [F(2, 57) = 12.62,
P \ 0.001], and ‘length of phrases’ [F(2, 57) = 4.38,
P = 0.017].
Comparing the positive and negative emotional terms
used by the two groups, it was found that 54 % of the
words used by the patient group were negative compared to
33 % used by normal children. Nonetheless, the difference
between the two groups in terms of positive and negative
terms was not significant.
Analyses revealed no correlations between the ToM
variables (intentionality, appropriateness, length of phrases
and emotional words) and inattention, hyperactivity,
oppositionality, and ADHD index in ADHD group.
Table 2 Characteristics of the two groups in terms of ToM variables
ADHD Normal
Mean SD Mean SD
Intentionality 18.96 7.67 25.34 8.88
Appropriateness 16.13 3.08 20.24 4.12
Length of phrases 23.29 4.72 19.48 4.78
Emotional words 2.04 1.44 2.10 1.44
One of the main aspects of social relationship is theory of
mind which refers to the ability to predict the others’
behaviors based on reading their minds. There are some
hypotheses explain the impairment in social relationship in
children with ADHD. Emotion dysregulation is one of the
hypotheses explains why these children cannot regulate
their emotions in different situations (Barkley 1997).
Moreover, it has been shown that youth with ADHD have
difficulty in perceiving and identifying facial expression
and emotions related to body gesture (Spencer 2006;
Tehrani-Doost et al. 2012). It has also been found that these
children have problems with comprehending emotional
cues in speech and face (Fonseca et al. 2009). The
impairment in social relationship can also be attributed to
difficulty in understanding others’ intentionality which is
one of the components of theory of mind. Based on this
concept, we conducted this study to assess comprehending
intentionality in children with ADHD compared to normal
developing children using the moving shapes paradigms.
The results showed that these children had a poorer
performance on understanding intentional behaviors. Our
results can confirm the hypothesis that, ToM deficits are
present in attention-deficit/hyperactivity disorder. More-
over, patients used significantly less mental state words
describing feelings and social interactions compared to
healthy controls.
The ‘appropriateness of answers,’ which is the appro-
priateness of descriptions to goals, was shown to be poorer
in children with ADHD. They were frequently referring to
mental states which were not appropriate to the expected
intentions. This variable requires tracing the content of
animations as well as grasping and interpreting the
sequencing and conclusion of the story (Abell et al. 2000).
Use of mentalizing language in describing animations is
based on giving the triangles a human role (e.g., mother
and son). This was being cued to look for social interac-
tions between the characters and to refer to mental states
(Abell et al. 2000). The weak performance of children on
this function can be interpreted as difficulties in under-
standing social cues. When it came to the length of phrases,
children with ADHD used more words and longer phrases
to describe animations as compared to controls. One of the
characteristics of these patients is speaking too much, while
P
their speech may lack an appropriate social content
(Barkley 2003). Although they used longer phrases, their
0.001 descriptions did not correctly match with the content of
0.001
story. With respect to number of emotional terms used,
0.01
there were not significant differences between the two
NS
groups. Nevertheless, the patient group used more negative
emotional terms such as anger, fear, and aggression as

123
Understanding intentionality in children with attention-deficit/hyperactivity disorder
compared to normal developing children who applied more
positive emotional words such as happiness and joy. This
result can be related to findings that individuals with
ADHD have deficits in understanding and describing
emotions expressed in others (Spencer 2006; Tehrani-
Doost et al. 2012). This impairment is another component
of social cognition which may lead to misunderstanding
emotional cues and applying negative emotional terms in
social relationship. Although emotion recognition and ToM
ability especially understanding intentionality can be rela-
ted together, it seems they are two different components of
social cognition.
The results of the present study are in line with Butielaar
et al. (1999) and Sodian et al. (2003) findings which
showed impairment in theory of mind ability among indi-
viduals with ADHD. On the other hand, Charman et al.
(2001), Perner et al. (2002), and Dyck et al. (2001) have
conversely shown that ToM ability in these patients are
similar to healthy controls. One explanation for this dis-
parity is the different types of tasks used in these studies.
The second-order ToM tasks which were used in these
studies reflect the ability of participant to comprehend false
beliefs. However, the task used in the current study rep-
resents the ability to recognize intentionality which is
different from false belief. Based on the results of the
current study, children with ADHD can have problems in
understanding others’ intentions. Therefore, they may
interpret other people’s behaviors as different attributions
and then response inappropriately.
One argument is that impairment in ToM may be related
to core symptoms of ADHD such as inattentiveness and
impulsiveness. To evaluate this, we conducted a correlation
analysis between ToM variables and ADHD symptoms
based on CPRS. The results showed no association
between these two variables. It can be interpreted that
deficit in theory of mind is another symptom which may
not be caused by impulsivity or inattentiveness and can be
considered as a cognitive deficit in these individuals. Fur-
ther studies with more precise assessments are needed to
find any causal relation between ToM ability and core
symptoms of ADHD. Another explanation is that theory of
mind can be related to executive functions which have been
shown their deficits in ADHD. To find this association we
need another study using ToM tasks and executive func-
tions test in a large group of children and adolescents with
ADHD.
Conclusion
It can be concluded that children with ADHD can have
difficulties in theory of mind ability, especially intention-
ality. This deficit can explain their impairment in social
relationship. The current findings are assumed to bring
along specific insights for interventions in these children.
Based on these insights, theory of mind training can
improve social interaction in children with ADHD. Further
studies using different kinds of theory of mind tasks with
different types of ADHD are recommended. We also need
to clarify whether the theory of mind deficit is caused by
the other core symptoms of ADHD or can be considered as
a different component of this disorder.
Limitations
The findings of this study should be interpreted in light of
its limitations including the small sample size, imple-
menting one type of theory of mind task, a narrow age
group, and limiting to boys. Moreover, it was better to be
used a semi-structured interview to confirm the diagnosis
and find the co morbidities. We did not also use teacher
report to confirm the severity of ADHD symptoms. The
two groups had significant differences in terms of their IQs
which can influence the ability of children in doing cog-
nitive tasks, although the results were obtained using the IQ
as covariate.
Acknowledgments This study was a part of the first author’s thesis
in obtaining M.Sc. in Cognitive Sciences at the Institute for Cognitive
Science Studies. We thank all children and their parents for their
contribution to this study.
Compliance with ethical standards
Conflict of interest There is no conflict of interest for none of the
authors.
References
Abell F, Happe F, Frith U (2000) Do triangles play a trick?
Attribution of mental state to animated shape in normal and
abnormal development. Cogn Dev 15:761–767
American Psychiatric Association (2000) Diagnostic and statistical
manual of mental disorders (DSM-II), 4th edn. American
Psychiatric Association, Washington (Text revision)
American Psychiatric Association (APA) (1994) Diagnostic and
statistical manual of mental disorders, 4th edn. American
Psychiatric Association, Washington
Barkley RA (1997) ADHD and the nature of self-control. The
Guilford Press, New York
Barkley RA (2003) Attention-deficit/hyperactivity disorder. In: Mash
EJ, Barkley RA (eds) Child psychopathology, 2nd edn. The
Guilford Press, New York, pp 75–143
Bruncm M, Brunce-Cohrem U (2005) Theory of mind—evaluation
ontogeny, brain mechanism and psychology. Neurosci Behav
Rev 30:437–455
Butielaar J, Wees VD, Barneveld HS, Jan vandergaag R (1999)
Theory of mind and emotion recognition functioning in autistic
spectrum disorders and in psychiatric control and normal
children. Dev Psychopathol 11:39–58
Castelli F, Happe F, Frith U, Frith C (2000) Movement and mind;
functional imaging study of perception and interpretation of
123

complex intentional movement pattern. NeuroImaging
12:314–325
Castelli F, Frith C, Happe F, Frith U (2002) Autism, Asperger
syndrome and brain mechanisms for the attributions of mental
states to animated shape. Brain 125:1839–1849
Charman T, Carrol F, Sturge C (2001) Theory of mind, executive
function and social competence in boys with ADHD. Emot
Behav Diffic 6(1):31–48
Dyck MJ, Ferguosen K, Shochet IM (2001) Do autism spectrum
disorders differ from each other non-spectrum disorders on
emotion recognition tests? Eur Child Adolesc Psychiatry
10(2):105–116
Faraone SV, Biederman J, Mick E (2006) The age-dependent decline
of attention deficit hyperactivity disorder: a meta-analysis of
follow-up studies. Psychol Med 36:159–165
Fonseca D, Seugiar V, Santos A, Poinso F, Deruelle CH (2009)
Emotion understanding in children with ADHD. Child Psychi-
atry Hum Dev 40:111–121
Gaub M, Carlson CL (1997) Gender differences in ADHD: a meta-
analysis and critical review. J Am Acad Child Adolesc
Psychiatry 36:1036–1045
Greene RW, Biederman J, Faraone SV, Sienna M, Garcia-Jetton J
(1997) Adolescent outcome of boys with attention-deficit/
hyperactivity disorder and social disability: results from a 4-year
longitudinal follow-up study. J Consult Clin Psychol 65:758–767
Koelkebeck K, Pedersen A, Suslow T, Kupper KA, Arolt V,
Ohermann P (2010) Theory of mind in first episodic schizophre-
nia patients: correlation with cognition and personality trait.
Schizophr Res 119:115–123
Mohammadzadeh A, Tehrani-Doost M, Khorrami-Banaraki A (2012)
Evaluation of theory of mind (intentionality) in primary school
123
A. Mohammadzadeh et al.
children using movement shape paradigm. Procedia Soc Behav
Sci 32:69–73
Nigg JT, Quamma JP, Greenberg MT, Kusche CA (1999) A two-year
longitudinal study of neuropsychological and cognitive perfor-
mance in relation to behavioral problems and competencies in
elementary school children. J Abnorm Child Psychol 27:51–63
Nijmeijer JS, Minderaa RB, Buitelaar JK, Mulligan A, Hartman CA,
Hoekstra PJ (2008) Attention-deficit/hyperactivity disorder and
social dysfunctioning. Clin Psychol Rev 28(4):692–708
Perner LJ, Lang B, Kloo D (2002) Theory of mind and self-control:
more than common problem of inhibition. Child Dev
73:752–767
Polanczyk G, Rohde LA (2007) Epidemiology of attention-deficit/
hyperactivity disorder across the life span. Curr Opin Psychiatry
20:386–392
Shamay-Tsoory SG, Aharon-Peretz J (2007) Dissociable prefrontal
networks for cognitive and affective theory of mind: a lesion
study. Neuropsychologia 45(13):3054–3067
Sodian B, Hulsken C, Thoermer C (2003) The self and action in
theory of mind research. J Conscious Cogn 12:777–782
Spencer TJ (2006) ADHD and co morbidities in childhood. J Clin
Psychiatry 67:27–31
Sprong M, Schothorst P, Vos E, Hox J, Van Engeland H (2007)
Theory of mind in schizophrenia: meta-analysis. Br J Psychiatry
191:5–13
Tehrani-Doost M, Noorazar G, Shahrivar Z, Khorrami A (2012)
Facial emotion recognition in boys with attention deficit
hyperactivity disorder. Neuropshyciatrie 60(5):S272–S273