Structural Relationships between Theory of Mind and Risky Behavior in Children with Attention Deficit/Hyperactivity Mediated by Psychological Maltreatment

This study aimed to investigate the structural relationship between the theory of mind (TOM) and risky behavior in children with attention-deficit/hyperactivity by mediating psychological maltreatment. The research method is descriptive-correlational. The statistical population of this study was all children aged 8 to 12 years in Tehran. The sample consisted of 316 children with ADHD in Tehran referring to psychiatric clinics who were selected by the available sampling method. Psychological Maltreatment (Fidel, 1989), the Eyberg Child Behavior Inventory (Eyberg and Pincus, 1999), and the Theory of Mind Questionnaire (Steememan, 1994) were used to collect the research data. Structural equation modeling was used to evaluate the proposed model using AMOS version 24 and SPSS 27. The results of the correlation coefficient showed that there is a negative relationship between TOM and psychological maltreatment and risk-taking behaviors (P<0.05). Findings indicate that the proposed model fits the data appropriately. The results of the structural model showed that 17% of the variance of psychological maltreatment is explained by TOM and 56% of the variance of risk-taking behaviors is explained by TOM and psychological maltreatment. It can be concluded that deficits in TOM in interaction with the perception of psychological maltreatment in children with ADHD can be a precursor to risky-taking behaviors in children. Therefore, risk-taking behaviors and impulsive behaviors in children with ADHD require evidence-based psychological interventions.
Keywords: Theory of Mind, Risk-Taking Behaviors, ADHD, Psychological maltreatment, Children.
 
Introduction
Attention Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder defined by persistent patterns of inattentiveness and hyperactivity/impulsivity that cause impairment in several areas of life (American Psychiatric Association, 2013; Dekkers et al., 2020).  The prevalence of ADHD in children and adolescents is estimated to be 4 to 6 percent (Miklós et al., 2019). The prevalence of this disorder in Iranian children aged 6 to 11 years is estimated to range from 6.33 to 8.66 (Piroti et al., 2021). ADHD is one of the most common psychiatric disorders in childhood (Polanczyk et al, 2014); in addition to the damage, it has for children and their families, the financial burden caused by the lack of attention and overactivity for society is also high (Robb et al., 2011; Dekkers et al., 2020). A significant part of these costs is related to risk-taking behaviors (Matza et al., 2005). ADHD has been linked to a variety of risky behaviors (risk-taking) in real life, such as substance abuse, risky driving, gambling, or unsafe sex (Pollak et al., 2019). Also, in laboratory risky behaviors, children and adolescents with ADHD show higher risk-taking behaviors than the control group (Dekkers et al., 2016). In general, considering that impulsive behaviors in children and adolescents with ADHD can increase their vulnerability to risk-taking behaviors (Crone, & Dahl, 2012), it seems important to study the basic mechanisms that can help to understand our theoretical knowledge and ultimately reduce risky behaviors in this group of individuals. Several empirical studies show that peer presence and encouragement increase risky behaviors in growing adolescents (Gardner, & Steinberg, 2005; Chein et al., 2011; Cavalca et al., 2013; Smith et al., 2014). According to the widely used dual systems model (Steinberg, 2010), this increase in risky behaviors during adolescence can be explained by the faster development of social-emotional brain systems than cognitive control systems, which increases reward-seeking behavior (Strang et al., 2013; Dekkers et al., 2020). The results of studies show that children with ADHD have problems with theory of mind (TOM) compared to children without neurodevelopmental disorder (Maoz et al., 2019). The theory of mind is involved in social cognition, as it evaluates our ability to attribute our states of mind to others to predict and explain behavior (Coelho et al., 2023). Theory of mind is defined as the ability to deduce a range of states within the mind, including beliefs, intentions, desires, and emotions (Premack, & Woodruff, 1978; Tesfaye, & Gruber, 2017).  impaired theory of mind with poor social interactions (Slaughter et al., 2015), psychiatric disorders (Bora, & Berk, 2016; Imuta et al., 2016), and various neurodevelopmental disorders (Baron-Cohen, 2000). In general, the study of executive functions and emotional functioning in children with ADHD is of particular importance. First, ADHD is one of the most common neurodevelopmental disorders identified in childhood, affecting approximately 5% of school-age children (American Psychiatric Association, 2013). Second, children with ADHD have social impairments, including rejection by peers, compared to normal and developing peers (Mikami, 2010; Imuta et al., 2016), impaired expression of empathy (Braaten, & Rosén, 2000; Maoz et al., 2019) and report lower social competence (Ronk and et al., 2011). According to this viewpoint, the present study aimed to investigate the structural relationships between the theory of mind and executive functions with risky behavior in children with attention-deficit/hyperactivity disorder mediated by psychological maltreatment.
Materials & Methods
This research was fundamental in terms of purpose and a descriptive-correlational study of the type of structural equation modeling (SEM), specifically structural regression equations (a combination of path analysis and factor analysis). The statistical population of this study consisted of all children aged 8 to 12 years in Tehran who were diagnosed with attention deficit hyperactivity disorder based on the opinion of a psychiatrist. A total of 316 children aged 8 to 12 years old in Tehran who were referred to medical centers and psychiatric offices between March 2023 and November 2023 and their diagnosis was confirmed by a psychologist and psychiatrist of these centers were selected by convenience sampling method. To test the research hypotheses, the structural model was tested, and then the bootstrap test with 2000 sampling was used to evaluate the mediating relationships. Data were analyzed using SPSS.27 and AMOS.24 software.
Discussion & Result
The results of the Pearson correlation coefficient showed that there is a negative and significant relationship between theory of mind and psychological maltreatment (r=-0.36, P<0.001) and risky behaviors (r=-0.59, P<0.001).  Also, there is a positive and significant relationship between psychological maltreatment and risky behaviors (r=0.61, P<0.001) in children with ADHD.  The results of structural equation modeling (SEM) showed that the standard and direct coefficient of the theory of mind was significant for psychological misbehavior (β=-0.266, P<0.001), theory of mind for risky behaviors (β=-0.283, P<0.001) and psychological maltreatment for risky behaviors (β=0.619, P<0.001).
Conclusion
This study aimed to investigate the structural relationship between the theory of mind and risky behavior in children with attention-deficit/hyperactivity disorder mediated by psychological maltreatment. The results of structural equation modeling showed that the theory of mind has a direct and negative effect on the risky behaviors of children with attention deficit hyperactivity disorder.  In line with these findings, Miranda et al. (2017) believe that the deficit in theory of mind in children with attention deficit hyperactivity disorder is not similar to that of children with autism (in which theory of mind is pronounced) and normal children (in which theory of mind is normal), but rather some degree of deficit is observable in these children. Children with attention deficit hyperactivity disorder perform poorly in the realm of social relationships, but they perform better in establishing relationships and interacting with others, this ability of children with attention deficit hyperactivity disorder in communication, along with gaining experience and knowledge of people's relationships, behaviors, and intentions, strengthens their mind reading. Also, the results of structural equation modeling showed that the theory of mind has a negative and indirect effect on the risky behaviors of children with attention deficit and hyperactivity through psychological maltreatment. In explaining these results, it can be said that the way we behave and control our emotions plays an important role in the way we relate to others. People who have problems with the theory of mind are more likely to have more trouble regulating their emotions than other people. Therefore, when these people cannot manage and regulate their emotions, it becomes difficult for them to control their behavior.