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Alkalayand Dan
Child and Adolescent Psychiatry and Mental Health (2022) 16:93
https://doi.org/10.1186/s13034-022-00526-2
REVIEW
Eect ofshort-term methylphenidate
onsocial impairment inchildren withattention
decit/hyperactivity disorder: systematic review
Sarit Alkalay*† and Orrie Dan†
Abstract
Attention Deficit/Hyperactivity disorder (ADHD) is one of the most common disorders in school-age children. In addi-
tion to learning difficulties associated with the disorder’s core symptoms of inattention and hyperactivity, children
with ADHD display substantial social impairments. Methylphenidate (MPH) in formulations such as Ritalin or Concerta
mitigates inattention and hyperactivity, but the effects of the therapy on social behavior in children with ADHD are
not clear. This review aims to determine the effectiveness of short term (up to 6 months) MPH treatment on three
domains of social skills in children aged 6–14 with ADHD: (i) Recognition of nonverbal emotional expressions, which
are a marker of inherent (unlearned) social understanding, (ii) theory of mind (ToM) components that relate to learned
cognition and social communication, and (iii) social competence in everyday environments. 15 relevant studies were
identified based on inclusion/exclusion criteria. The results show mixed effects: the overall social performance as
evaluated by parents, teachers or peers, and some components of ToM, were found to improve following a weeks-
long course of MPH treatment. However, the effects of the medication are less clear when evaluating momentary/
nonverbal social responses such as reactions to emotional facial expressions. While the findings of this review indicate
that an MPH medication regime of order weeks to months could improve, to a degree, social impairment in children
with ADHD, more studies are required to identify the medications’ mechanism and confirm such a conclusion.
Keywords: Attention deficit hyperactivity disorder (ADHD), Methylphenidate, Children, Theory of mind, Non-verbal
emotional cues, Social behaviors
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Introduction
Attention-Deficit/Hyperactivity disorder (ADHD) affects
an estimated 2–12% of school-age children worldwide
(see, for example, [1–7]). Increasing awareness has led to
the diagnosis of many children as early as pre-school or
the first years in school, namely ages 4–8 (see, for exam-
ple, [8]).
e disorder is defined by a range of inattention and/
or hyperactivity–impulsivity symptoms [9, 10] that
cause impairments in cognitive domains (see, for exam-
ple, [10–13]). Somewhat less discussed, but also preva-
lent in individuals with ADHD are deficiencies in social
competences, namely, social behavior, social cognition,
and social outcomes [14–30]. For example, children with
ADHD display a tendency to interrupt others, fail to fol-
low instructions, and exhibit aggression and rule break-
ing [31–36]. e result in some cases is rejection by their
peers [26, 37–41] and/or poor friendship quality [37–40],
which may lead to lifetime-long maladjustment (see, for
example, [42]).
Methylphenidate (MPH) in formulations such as
Ritalin© or Concerta© has been found to be highly effec-
tive in the treatment of ADHD symptoms, alone or in
Open Access
Child and Adolescent Psychiatry
and Mental Health
†Sarit Alkalay and Orrie Dan have equal contribution to this work
*Correspondence: sarital@yvc.ac.il; saritalkalay@gmail.com
Department of Psychology, The Center for Psychobiological Research, Max
Stern Jezreel Valley Academic College, P.O.B. 72, 10806 Sede Nahum, Israel
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Page 2 of 12
Alkalayand Dan Child and Adolescent Psychiatry and Mental Health (2022) 16:93
combination with behavioral therapy, (see, for example,
[43, 44]). As a result, MPH is recommended as the first
line of treatment for ADHD and is the most broadly pre-
scribed ADHD medication for children and adolescents
[45–49]. MPH has been shown to improve the perfor-
mance of children with ADHD on measures of atten-
tion, impulsivity and memory, as well as reduce omission
errors (namely, no response to target stimuli, linked to
inattention) and commission errors (response to non-tar-
get stimuli, associated with impulsivity) (see, for example,
[50–52]).
Appropriate social functioning is a complex decision-
making process based on the understanding of emotional
and motivational states in others, the application of prior
learning of social norms to the choice of behavior, and
the ability to act appropriately [53]. As a result, social
skills require both long-term learning (i.e., knowledge of
acceptable social behaviors) and ‘in the moment’ compo-
nents (i.e., acquisition of situational inputs and enacting
appropriate responses) [53]. In ADHD, it is suggested
that acquisition is intact (i.e., children with ADHD pos-
sess knowledge about “what to do”), but performance and
fluency are impaired (they “don’t do what they know”)
[46, 54–56]. Performance issues are related to misun-
derstanding and mis-interpretation of emotional cues or
emotional facial expressions (see, for example, [57–59],
while fluency is demonstrated by weak social problem-
solving skills [33, 60–62]. It is expected that MPH would
improve momentary processes in children with ADHD,
namely, the encoding of emotional inputs or the abil-
ity to control actions. Indeed, reports by parents and
teachers suggest that children treated with MPH show
improvement in social interactions and a reduction in
oppositional or aggressive behavior at home and in the
classroom [51]. However, it is unclear whether MPH
treatment also affects long-term acquisition of social
behaviors, and thus the overall social performance of
children with ADHD.
e aim of this review is to examine the effects of
MPH on specific components of social performance in
children 6–14years old with ADHD. We chose this age
range based on several considerations. First, diagnosis
of preschoolers with ADHD is complicated due to other
aspects of their development (see, for example, [63]). As
a result, younger children are more likely to be diagnosed
with ADHD during their early school years- namely
around age 6 (see, for example, [64–66]). is is also
enhanced by the transition of children from the family
as their core social environment to a peer-based focused
environment which starts when they enter school at age
6, when deficits in the social domain become more appar-
ent (see, for example, [67]). Once diagnosed, treatment is
likely to follow age-specific treatment guidelines as set
by the American Academy of Child and Adolescent Psy-
chiatry [68, 69] and the American Academy of Pediatrics
[AAP] [70] that recommend for preschool-age children
diagnosed with ADHD parent- or teacher- administered
behavior therapy as the first-line treatment. However, for
children 6years of age and older, the AAP recommends
prescribing medication and/or behavior therapy, with a
preference for both treatments in combination [68–70].
Our cutoff at the older age range of our sample is
11–13, namely, pre-adolescence [71]. ADHD changes
with age, especially in the adolescent years (see, for exam-
ple, [72–74]): the major physical changes in adolescence
affect emotions, cognition, and social interactions [75]
which are at the heart of ADHD manifestation and our
study. To avoid a possible obscuring effect due to those
hormones-related changes, we did not include studies
with participants older than 14.
ree domains of social skills are examined, as repre-
sentatives of the different steps in the execution of social
performance:
– Recognition of emotional inputs, as measured
through accurate identification of emotions: com-
munication of emotions is a core, essential step in
social functioning. Individuals that are impaired in
their ability to recognize emotions in others cannot
perform socially in a competent manner [20, 23, 30].
Some processes of emotion communication, such as
facial expressions, have been shown to be fundamen-
tal and universal [76–88], implying that humans are
biologically “hard-wired” to recognize them. Tests
present simple emotional cues: pictures of emotional
facial expressions, postures, gestures, or other par-
alanguage cues. us, these tests are largely inde-
pendent of cognitive assessment or prior learning,
and evaluation of the effect of MPH on performance
yields information on the ‘in the moment’ processes
that do not rely on experiences.
– ‘eory of mind’ (ToM): ToM is a components of
social cognition that relates to the skills required to
manage social communication and relationships [89].
In typically developing children, ToM is attained by
age 3–4 through social interactions that promote
conceptualization of the abstract and subjective
nature of mental processes and psychological cau-
sality [89]. e result is the ability to note motives,
beliefs, and feelings in others. However, gaining and
refining ToM continues throughout the school years
and into adulthood [89]. ToM development depends
on memory systems (e.g., short- and long- term
declarative memory, emotional memory), on lan-
guage, and onexecutive functions. As a result, tests
of the effect of MPH on ToM in children with ADHD
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Alkalayand Dan Child and Adolescent Psychiatry and Mental Health (2022) 16:93
examines the accumulation of social and emotional
concepts.
– Social competence (as assessed by self, peers, fam-
ily and/or teacher evaluations): social competence is
generally defined as the effective functioning of indi-
viduals within social context, and may be divided into
three aspects: attainment of society-defined accom-
plishments, global (external) judgment of social com-
petences, and evaluation of peer acceptance [90].
Assessment of social competence therefore reveals
the long-term experience of the individual and their
perception. Laboratory experiments evaluate the
temporary effect of MPH on a specific social func-
tion. However, using evaluation of social competence
through self, peer, parental or teacher evaluations
provides understanding of the effect of the medica-
tion on the child’s actual, everyday performance,
encompassing short-term and long-term aspects.
Better understanding of the effects of MPH on these
three domains will enable answering questions important
for the treatment of children with ADHD, such as: does
medication with MPH improve social deficits in children
with ADHD? If it does, are the effects short term and ‘in
the moment’, or long term? Answers might help design
appropriate medication regimes to address social deficits
in children with ADHD.
Methods
We follow a framework adapted from Whittemore and
Knafl [91] for the conduction of integrated reviews, and
relevant aspects of the PRISMA 2020 [91]. e process is
divided into several stages that include problem identifi-
cation, search of the literature, data extraction and evalu-
ation, data analysis and presentation of the results.
Data sources andsearches
e search included papers published between 1980 and
2021 in APA PsycNet, MEDLINE, PubMed, ISI Web of
Science, Scopus.
Study selection
Studies were eligible for the review if they were peer
reviewed and published in the English language. Inclu-
sion criteria were based on the following Boolean
descriptors: (ADHD OR “attention deficit disorder” OR
“attention deficit hyperactivity disorder” OR “attention-
deficit/hyperactivity disorder”) AND (social) AND
(methylphenidate OR MPH or stimulant) AND (children
OR youth). Exclusion criteria included:
- non-reviewed publications (e.g., conference papers,
MS or PhD thesis), papers published in languages
other than English, or review papers.
- studies in which the average age of the participants
was not in the target range of 6–14years.
- case studies (namely, studies with a small sample
size of less than 6 participants).
- studies where the participants were not consist-
ently diagnosed with ADHD based on DSM III [93],
DSM IV [94] or DSM V [9].
- studies where a substantial fraction (40% or more)
of the ADHD group had additional psychological
disorders, namely, comorbidities, such as opposi-
tional defiant disorder (ODD), conduct disorder
(CD), or learning disability (LD).
- studies where the ADHD group was also medi-
cated with drugs other than MPH.
- studies whose focus was on comparing different
formulations or dosages of MPH.
- studies where the effects of medication were eval-
uated after more than 12 months of a medication
regime: Social cognition in children changes rela-
tively rapidly, so that such long-term studies may
include effects not directly related to the medication.
Screening anddata extraction
e abstracts were assessed by the authors to evaluate
compliance with the inclusion/exclusion criteria. Papers
that complied with the criteria were then read in total.
e authors extracted the relevant data including testing
methodology, tested traits/behaviors, and outcomes.
Results
Study selection andcharacteristics
Database Boolean search results yielded 626 papers.
ese were examined individually by the authors to
exclude those that did not comply with the exclusion cri-
teria listed above. e process is described in Fig.1.
Table 1 lists the 15 papers that satisfied the criteria
for this review, and the basic study parameters: size of
the study (defined by the number of participants with
ADHD), age range, and gender distribution. Also noted
is the distribution of ADHD sub type (when specified):
(I)- predominantly inattentive type, (H)- predominantly
hyperactive/impulsive type, (C)- combined type. Tests
conducted include: reading the Mind in the Eyes Test
(RMET); Benton Face Recognition Test (BFRT); Empa-
thizing Quotient (EQ); Suspiciousness Rating Scale
(SRS); Bryant Index of Empathy (BEI); Griffith Empathy
Measurement (GEM); Empathy Response Task (ERT);
Diagnostic Analysis of Nonverbal Accuracy-2 (DANVA-
2); Social Perception Behavior Rating Scale (SPBRS); Life
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Alkalayand Dan Child and Adolescent Psychiatry and Mental Health (2022) 16:93
Participation Scale (LPS); Interpersonal reactivity index
(IRI); “faux-pas” recognition task (FPR); Social Adjust-
ment Inventory for Children and Adolescents (SAICA);
Event Related Potential (ERP).
Eect ofMPH onrecognition ofemotional inputs
e Diagnostic Analysis of Nonverbal Accuracy
(DANVA) was used by Hall etal. [102] to examine the
response of children with ADHD to images of adults
and children showing various emotions though facial
expression, gestures, or paralanguage cues. e ADHD
participants were previously diagnosed with ADHD
and were receiving MPH for treatment of the disorder
at the time of the study. ey were tested twice: once
while medicated and once after a ‘washout’ period of
at least 24h. eir results were also compared to those
of matched group of typically-developing (TD) chil-
dren acting as control. No significant differences were
found between the TD control group and the ADHD
group either when medicated with MPH or when
Individual papers identified
based on Boolean inclusion
criteria from databases yielded
626 studies between 1980-2022
years.
Records screened based on
abstracts
(n = 105)
Recordsexcluded based on
abstracts only
(n =74)
Papers retrieved and assessed
for eligibility based on full text
(n =31)
Exclusion based on the stated
criteria (age group, other
psychological disorders, non-
DSM diagnosis, etc.)
(n = 16)
Studies included in review
(n =15)
Identification
Screening
Included
Exclusion of papers which were
non-refereed or conference
abstracts, other languages then
English, not peer reviewed, and
based on title(n=521)
Fig. 1 The review process flow diagram
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Alkalayand Dan Child and Adolescent Psychiatry and Mental Health (2022) 16:93
un-medicated, in all aspects of the DANVA evalua-
tion (facial expression, gestures, or paralanguage) [102]
(It should be noted that the study also included a group
of children with ADHD and LD, but the results of this
group are outside this review’s parameters).
Kobayashi et al. [104] investigated the hemodynamic
response in the temporal and occipital regions of children
Table 1 Demographic and study data for the reviewed papers
a This number represents only the children in the ADHD group. Some studies also included a group of ADHD + a specic comorbidity (e.g., ODD), but these were not
taken into account and are not presented in this table
b (I): predominantly inattentive type, (H): predominantly hyperactive/impulsive type, (C): combined type
c Of the entire study, namely, ADHD + Typically Developing (TD) groups
d 25% not specied/determined
e The total number of ADHD children was 60; However, only 38 of them received MPH, while the others received atomoxetine. Statistics are for the entire ADHD group
f The study also included a group of children with ADHD and ODD, which we did not include in our analysis
1st Author Year Age range
(Average ± SD) Number ADHD
groupaMale (%) SubtypebGroups and
control Dependent variable
Abikoff [95, 96] 2004 7.0–9.9 (8.2 ± 0.8) 34 93% Not noted 3 experimental, no
control Social functioning
-Parent, child, and
teacher ratings
Bottelier [97] 2017 10–12 35 100% 60%I, 40%C 1 experimental, 1
control Amygdala reactivity
Demirci [17] 2016 8–15 (10.8 ± 1.5) 38348%e37%I, 28%H, 35%Ce3 experimental, 1
control Face and emotion
recognition (RMET;
BFRT)
Golubchik [98] 2019 7–17 (10.8 ± 2.7) 25 84% Not noted 1 experimental, No
control Face and emotion
recognition (RMET)
Golubchik [99] 2017 8–18 26fNot specified Not noted 1 experimental, No
control Empathy (EQ)
Golubchik [100] 2018 8–18 (12.9 ± 2.5) 30f58% Not noted 1 experimental, 1
control Suspiciousness (SRS)
Gumustas [101] 2017 8–14 (10.86 ± 1.85) 65 82% Not noted 1 experimental, 1
control Empathy and emo-
tion expression rec-
ognition (BEI; GEM;
ERT; DANVA-2)
Hall [102] 1999 7–10 15 80%c77% C, 8.5% H 2 experimental, 1
control Emotion expres-
sion recognition
and social percep-
tion (DANVA;SPBRS)
Kim [103] 2015 6–18 (9.4 ± 2.4) 116 86% 33.6%I, 5.2%H,
36.2%Cd1 experimental, No
control Self control (LPS)
Kobayashi [104] 2020 8–10 (9.8 ± 1.3) 19 95% 21% I, 79% C 1 experimental, No
control Response to facial
expressions meas-
ured by oxyhemo-
globin responses
in the right inferior
occipital region
Levi-Shachar [105] 2020 6–12 (9.4 ± 1.6) 50 56% Not noted 1 experimental, 1
control Social cognition and
Oxytocin level
Maoz [106] 2014 6–12 24 67% 54% I, 46% C 1 experimental, No
control Interpersonal Reac-
tivity Index, Theory of
Mind and Empathy
(IRI; FPR; computer-
ized ToM task)
Maoz [107] 2019 (10.28 ± 1.64) 24 66% Not noted 1 experimental, 1
control Theory of Mind and
Empathy (IRI; FPR)
Shang [108] 2020 7–16 (9.61 ± 2.41) 168/83 mph 87% Not noted 2 experimental Social adjustment,
Social Adjustment
Inventory for Chil-
dren and Adoles-
cents (SAICA)
Williams [109] 2008 8–17 (13.79 ± 2.33) 51 100% Not noted 1 experimental, 1
control Response to facial
expressions (ERPs)
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Alkalayand Dan Child and Adolescent Psychiatry and Mental Health (2022) 16:93
with ADHD when presented with angry or happy facial
expressions. All children were regularly medicated with
MPH prior to the study. A double-blind test was con-
ducted in two sessions that followed a washout period
of 4days. In each session, children underwent a baseline,
medication-free test, followed by a post-medication test
using wither MPH or a placebo. e researchers [104]
found that MPH did not affect the response to happy
facial expressions, which involved a significant increase
in the oxygenated hemodynamic (oxy-Hb) in the right
inferior occipital area. In contrast, the response to angry
expressions showed a significant increase after MPH
administration in the left inferior occipital area when
compared to the medication free or placebo.
In a functional Magnetic Resonance Imaging (fMRI)
study, Bottelier etal. [97] examined the activity in the
amygdala in drug-naïve children with ADHD that were
presented with angry or fearful faces (as well as neutral
images). e children were tested before and after the
administration of a short-acting MPH dose and com-
pared to TD children. e researchers [97] found that
MPH did not affect the response in the left amygdala but
did reduce the response in the right amygdala. In both,
the TD response was much higher, so that in regard
to the right amygdala, MPH increased the difference
between ADHD and TD groups. However, theresearch-
ers noted that amygdala reactivity did not correlate with
emotional dysregulation as measured with clinical rating
scales [97].
A somewhat different methodology was used by Wil-
liams etal. [109] and Gumustas etal. [101], where the
effect of MPH on the recognition of emotional facial
expressions in children with ADHD was examined. Tests
were conducted at baseline, before the start of MPH
treatment, and again after a period of MPH administra-
tion (4weeks [109] or 12 weeks [101]). e majority of
the children with ADHD in these studies were drug naïve,
and the others underwent a ‘washout’ period before the
baseline testing. In addition, the ADHD group’s results
were compared to those of a matched TD control.
Gumustas etal. [101] found that the accuracy of emo-
tional facial expressions was lower in the ADHD group
at baseline (pre-treatment) when compared to the TD
group. However, the differences were not statistically sig-
nificant. After 12weeks of MPH treatment, errors in the
recognition of happy and fearful expressions remained
the same, but accuracy in identification of sad and angry
faces increased but not in a statistically significant man-
ner. Williams etal. [109] found that the accuracy of facial
emotion recognition pre-treatment in the children with
ADHD was the same for neutral, happy and sad expres-
sions. It was statistically significantly lower, however, for
angry and fearful expressions. Following 4weeks of MPH
treatment (and performance of the test while medicated),
the children with ADHD showed a significant improve-
ment in their ability to identify fear and anger. How-
ever, their performance for these expressions remained
impaired when compared to the TD controls [109].
Theory ofmind (ToM) studies
e ‘reading the mind in the eyes’ test (RMET) examines
ToM by using photos of the eye region, where participant
are asked to identify the emotion portrayed. Unlike the
facial expression pictures (e.g., in DANVA) where emo-
tions are clearly defined, RMET illustrates complex men-
tal states such as ‘‘embarrassed’’ and require application
of ToM concepts of inferences.
Golubchik et al. [98] tested the performance of chil-
dren with ADHD in the children’s version of RMET,
before and after receiving a dose of MPH. e study con-
firmed that RMET assesses ToM in the ADHD group by
correlating it to social functioning as evaluated by the
SDQ screening questionnaire that investigates emotional
symptoms, conduct problems, hyperactivity/inattention,
peer relationship problems and prosocial behavior. Base-
line (un-medicated) testing showed an effect of age but
not ADHD severity as evaluated by ADHD rating scale
(ADHD-RS) score. No significant change in the RMET
score was found between the baseline/un-medicated and
medicated with MPH tests. It should be noted that the
previous medication history of the ADHD group was not
clearly stated.
Demirci etal. [17] tested the long term effect of MPH
on children with ADHD using RMET. e baseline, med-
ication-free RMET found that the ADHD group had a
significantly higher number of errors than a matched TD
control group, with the H subtype performing worse than
the I subtype. A 3month long MPH medication regime
led to improvement in performance (namely, reduction
in the number of errors) in the ADHD group.
Other aspects of ToM were examined by Maoz etal.
who used a ‘faux pas’ (FPR) [106, 107] test to measure the
ability of children with ADHD to recognize social situa-
tions in which a speaker says something without under-
standing that it could be misinterpreted. ey also used a
computerized task (TCT) [106] to test the children’s abil-
ity to judge mental states using verbal cues and eye gaze.
e children performed the tasks in two sessions: One
while medication-free after a washout period of at least
24h, and one after receiving a dose of long- acting MPH.
e researchers found that MPH administration led to
a significant improvement in performance on all tests.
Interestingly, children with poorer baseline ToM perfor-
mance showed greater improvement when medicated by
MPH [106, 107].
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Alkalayand Dan Child and Adolescent Psychiatry and Mental Health (2022) 16:93
More recently, Levi-Shachar et al. [105] examined
the effect of MPH vs. placebo on ToM in children with
ADHD using vignettes, stories, and drawings that assess
emotion recognition, first-order belief and false belief,
and advanced components (e.g., humor), as well as an
FPR test. Children who were on MPH regularly under-
went a washout period of 48 h, and then tested, once
when medicated with MPH, and once when taking a pla-
cebo. ey found that children with ADHD performed
worse than TD controls on the ToM test and FPR when
un-medicated (namely, medicated with a placebo). How-
ever, the differences between the two groups disappeared
when the children with ADHD were medicated with
MPH.
A related concept to ToM is empathy, which is defined
as an affective response based on an assessment of
another person’s emotional state. is definition encom-
passes the cognitive awareness of the inner state of
another person—that is, the emotions, thoughts, per-
spectives, and intentions of the other [101]. Gumustas
etal. [101] tested empathy in children with ADHD, using
the Bryant Index for Empathy (BEI), which evaluates
trait empathy, and the Empathy Response Task (ERT)
which evaluates state empathy. e ERT requires verbal
responses to fictitious episodes presented as a short nar-
rative about a child and illustrated with a picture where
facial features were blank. Responses were scored by
computing a match score and an interpretation score. It
was found that there were no statistically significant dif-
ferences between groups (TD, pre-treatment and after
12weeks of MPH medication) in terms of trait and state
empathy levels, although the medication regime did lead
to a significant increase in the interpretation sub scores
of empathy [101].
Eect ofMPH on(overall) social competencies
A number of studies followed the effect of MPH on
measures of overall social performance in children with
ADHD, using self, peer, parental or teacher evaluations.
Shang etal. [108] examined the effect of MPH on chil-
dren with ADHD using self and parent ratings through
the Social Adjustment Inventory for Children and Ado-
lescents (SAICA). e test was administered at baseline
and periodically following the start of MPH treatment.
Parental reports showed consistent and statistically sig-
nificant improvement after 8 weeks of MPH in both
school functions and peer relationships. is improve-
ment continued into week 16, after which it seemed
to stabilize. Child self-ratings showed similar trends,
although the improvement trend was weaker. Interest-
ingly, neither self nor parental reports observed signifi-
cant improvement in home and family behaviors.
Golubchik etal. assessed the effect of a 12week long
MPH treatment regime on the Emotional Quotient (EQ)
[99] and on suspiciousness and social-function related
items such as feeling teased, blaming others, feeling oth-
ers are out to get you and feeling suspicious of others
[100]. As expected, the treatment was shown to reduce
the ADHD-RS scores significantly, indicating a reduc-
tion in the severity of ADHD symptoms [99]. e MPH
regimen was found to increase the Emotional Quotient
(EQ) score in the children, indicating an improvement in
empathy, with changes in the EQ score significantly cor-
related with the changes in ADHD-RS [99]. Also, a small
but statistically significant reduction in the measures of
suspiciousness was observed [100].
Somewhat similar findings after a 12week long MPH
regimen applied to mostly drug-naïve children were
observed by Kim etal. [103]. Results from the Life Par-
ticipation Scale (LPS) showed some improvement in
the social/happy scales between baseline and post MPH
treatment, although the difference was statistically
minor. Analysis suggested that there is a degree of asso-
ciation between the medication-induced reduction in
ADHD symptoms and an improved adaptive function-
ing. It should be noted that although approximately 30%
of the children had comorbidities (depression, ODD, tic
or anxiety disorder), the relationship between changes in
the related comorbidity symptoms showed only a weak
to moderate degree of association when compared with
the association between ADHD core symptoms and
functioning.
Longer-term effects of MPH on children with ADHD
were studied by Abikoff etal. [95, 96], who compared the
baseline, medication-free tests to 6, 12, 18, and 24months
post treatment onset. Here we focus on the 6 month
results only, since as noted above, ageing by more than
this period can have significant effects on children. e
study used the self and parent Social Skills Rating Scale
(SSRS) which measures social skills problem behaviors
and academic competence, as well as teacher evaluations
through the Taxonomy of Problematic Social Situations
(TOPS), which yield a total score as well as scores for six
scales: peer group entry, response to peer provocations,
response to failure, response to success, social expecta-
tions, and teacher expectations. In addition, the research-
ers conducted direct observations of the children in the
school environment. After 6months of MPH treatment,
the self, parent, and teacher ratings showed significant
improvement in the children’s performance, as did the
observational data.
Overall social skills can also be tested in laboratory set-
tings. Pelham etal. [110] examined the effect of medica-
tion (MPH vs. placebo) and expectation of medication
using a peer-interaction task that encompassed a range of
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Alkalayand Dan Child and Adolescent Psychiatry and Mental Health (2022) 16:93
social skills: perception and interpretation of cues from
the other, information integration, choice and enactment
of a response. e study compared pre-task self-eval-
uation to performance as judged by self and by a tester.
ey found that medication expectancy did not affect
children’s performance. Moreover, children that received
the MPH did not differ from those that received placebo,
as evaluated both by self-report or by a research observer.
In contrast, social success, or failure (which were manip-
ulated by the researcher) had a significant effect on self-
assessment, regardless of medication status.
Discussion
ADHD has been linked to social impairment in children
[14, 15, 17, 20, 22–25, 27–30]. Stimulants, and in par-
ticular MPH, improve cognitive and scholastic deficits in
children with ADHD [43, 44]. e aim of this review was
to examine how MPH may affect components of social
deficits in children with ADHD. To that end, we divided
the studies into three categories: the effect of MPH on
recognition of emotional inputs, which relates to short-
term effects (i.e., ‘in the moment’ performance), onthe-
ory of mind (ToM), and onoverall social skills, both of
which relate to long-term effects.
Core emotional facial expressions such as happy or
angry are a universal method of emotion communication
that is largely independent of social learning [76–88].
Communication of emotions via nonverbal cues may be
more complex, but is also a relatively universal skill (see,
for example, [111]) that is closely linked to attention
[112]. Studies to date suggest that children with ADHD
experience some impairment in the recognition of emo-
tional facial expressions [25, 113], although broadly dif-
fering results vary as to the specific emotions that present
challenges. Since MPH is known to increase sustained
attention in children with ADHD (see, for example,
[114–116]), it is reasonable to assume that children with
ADHD would perform better on emotion recognition
tasks while medicated with MPH. On the other hand, it
is unclear whether long-term medication status (namely,
children who have been medicated with MPH over a
period of time) would have an effect in a similar way.
e results of studies examining the effect of MPH on
emotion recognition in children with ADHD are some-
what contradictory. Both Gumustas etal. [101] and Hall
etal. [102] did not find significant differences between
a TD control group and children with ADHD that were
tested while unmedicated, in contradiction of previ-
ous findings that show impairments [25, 113]. us, it
is possible that their study design was not sensitive to
the relevant deficits that are characteristic in children
with ADHD, and so their additional observation that
MPH (either after a 12 week-long medication regime
[101] or while conducting the test [102]) had no statis-
tically significant effect on performance is inconclusive.
e results of Williams etal. [109] may be more illumi-
nating: at baseline, namely pre-treatment with MPH and
medication-free during testing, they found that the accu-
racy of facial emotion in the ADHD group was poorer for
some expressions (angry and fearful) but not for others.
MPH significantly improved the children’s performance
[109]. However, the second set of tests was conducted
after 4weeks of treatment and while medicated, it is not
possible to conclude whether the effect of MPH was due
to long-term effects, or to the ‘in the moment’ increased
attention imparted by the medication.
e answer to this question is partially given in stud-
ies of brain activity: Bottelier et al. [97] used fMRI to
examine the response to angry or fearful expressions by
drug-naïve children with ADHD, while medication free
and while medicated with MPH. eir finding that the
medication affected the response in the right amygdala
[97] must be related to the medication’s ‘in the moment’
effect, since the children were not on a long-term medi-
cation regime. In the Kobayashi et al. [104] study, the
children were on a long-term medication regime, and
their response recorded while medication-free after a
washout period, medicated with MPH or with a placebo.
eir finding that there was a more pronounced response
to angry (but not to happy) expression while medicated
with MPH when compared to the baseline washout test
or the placebo, is also an indicator of an ‘in the moment’
effect. However, it is difficult to correlate these findings
regarding brain activity to attention or accuracy of emo-
tion recognition. us, more studies that clearly distin-
guish between the effects of long-term and short-term
use of MPH are needed.
e next type of studies examined aspects of ToM.
Meta-analysis shows that children with ADHD have
impaired ToM when compared to their TD counterparts
[60]. As noted above, ToM is typically developed by age
3–4 [89], well below the age at which most children are
diagnosed with ADHD [48, 49]. However, it continues to
evolve in older children, and is related to executive func-
tions [117]. e effect of MPH on ToM in children with
ADHD could be associated with its long-term effects
on executive functions and enhanced learning but could
also improve ‘in the moment’ performance by enhancing
attention during testing.
Regarding the short-term effect of MPH on ToM,
Golubchik et al. [98] did not find significant change
in RMET score between un-medicated and medicated
testing of children with ADHD. In contrast, Maoz etal.
[106, 107] found MPH enhanced the performance of
children when compared to testing while un-medi-
cated. Similarly, Levi-Shachar et al. [105] found that
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Page 9 of 12
Alkalayand Dan Child and Adolescent Psychiatry and Mental Health (2022) 16:93
children with ADHD performed worse than TD con-
trols when un-medicated, but matched the TD group
when medicated with MPH. Differences in the effect
of weeks-long MPH medication regime on ToM are
also observed: Demirci et al. found a clear improve-
ment after a 3months long medication regime [17], but
Gumustas etal. did not see any deficits before starting
the medication process (when compared to TD chil-
dren) or improvement after 12weeks of MPH [101].
Most evaluations of how MPH affects global aspects
of social performance in children with ADHD focused
on long-term medication regimes. Whether through
self, parental or teacher assessments, it is agreed that
medication with MPH for a period of 8weeks or more
improves social skills in children with ADHD [95, 96,
99, 100, 103, 104]. In contrast, laboratory testing did
not find a significant difference between performance
while medicated with MPH or a placebo [110].
Social performance in children is a multi-facet and
complex process. For example, Dodge’s Social Infor-
mation Processing (SIP) proposes six steps [53] that
include encoding of cues, interpretation and mental
representation of the cues, goal clarification, construc-
tion of possible responses, response evaluation and
decision, and behavioral enactment. Clearly, some of
them rely on momentary abilities (encoding of cues,
enactment of behavior) while others rely on acquired
learning of social behaviors. e studies reviewed here
demonstrate that overall social performance, and some
components of ToM, are improved by a weeks-long
regim of MPH treatment (reported effects after only
3months in some studies), and also after medication
during the testing situations only. However, despite
the expectation that the medication’s improvement in
aspects of attention would lead to better performance
‘in the moment’ (i.e., facial recognition), those effects
are less clear. It may be cautiously concluded, there-
fore, that an MPH medication regime continued over
time would improve social impairment in children with
ADHD. However, more studies are required to confirm
this conclusion and to clarify what is the duration of
medication needed for observing effects on the social
components of facial recognition, ToM and social
performance.
Author contributions
The two authors have equal contribution. Both authors read and approved the
final manuscript.
Funding
Not applicable. The authors did not receive support from any organization for
the submitted work.
Availability of data and materials
All data and materials are listed in the article.
Declarations
Ethics approval and consent to participate
Not applicable. No human participants, thus no ethical approval required.
Competing interests
Not applicable. The authors have no relevant financial or non-financial inter-
ests to disclose.
Received: 17 July 2022 Accepted: 14 November 2022
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