Impaired Theory of Mind and psychosocial functioning among pediatric patients with Type I versus Type II bipolar disorder

Psychiatry Research 215 (2014) 740–746

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Impaired Theory of Mind and psychosocial functioning among pediatric patients with Type I versus Type II bipolar disorder Lindsay S. Schenkel n, Todd F. Chamberlain, Terra L. Towne Department of Psychology, Rochester Institute of Technology, 18 Lomb Memorial Drive, Rochester, 14623 NY, USA

art ic l e i nf o

a b s t r a c t

Article history: Received 30 August 2012 Received in revised form 14 October 2013 Accepted 16 October 2013 Available online 7 December 2013

Deficits in Theory of Mind (ToM) have been documented among pediatric patients with Bipolar Disorder (BD). However, fewer studies have directly examined differences between type I and type II patients and whether or not ToM deficits are related to psychosocial difficulties. Therefore, the aim of this study was to compare type I versus type II pediatric bipolar patients and matched Healthy Controls (HC) on ToM and interpersonal functioning tasks. All participants completed the Revised Mind in the Eyes Task (MET), the Cognitive and Emotional Perspective Taking Task (CEPTT), and the Index of Peer Relations (IPR). Type I BD patients reported greater peer difficulties on the IPR compared to HC, and also performed more poorly on the MET and the cognitive condition of the CEPTT, but did not differ significantly on the emotional condition. There were no significant group differences between type II BD patients and HC. More impaired ToM performance was associated with poorer interpersonal functioning. Type I BD patients show deficits in the ability to understand another's mental state, irrespective of emotional valence. Deficits in understanding others' mental states could be an important treatment target for type I pediatric patients with BD. & 2013 Elsevier Ireland Ltd. All rights reserved.

Keywords: Pediatric bipolar disorder Theory of mind Psychosocial functioning

1. Introduction The diagnosis of Bipolar Disorder (BD) distinguishes two subtypes, BD type I and type II, largely on the basis of the presence of manic versus hypomanic episodes and a greater versus lesser degree of clinical impairment respectively. Deficits in social cognition and psychosocial functioning are now considered to be core features of pediatric BD (Pavuluri et al., 2005; Keenan-Miller and Miklowitz, 2011), and have been documented in both type I and type II pediatric BD patients (Washburn et al., 2011; Schenkel et al., 2012a). A number of investigations have documented significant interpersonal difficulties among youth with BD, including more problematic and conflictual relationships with family members and peers (Schenkel et al., 2008a; Goldstein et al., 2009). Emotion processing impairments have also been documented in pediatric BD patients (Schenkel et al., 2007, 2012a), and are thought to be an important endophenotype for the disorder (Brotman et al., 2008; Rich et al., 2008). A few studies have examined other aspects of social-cognitive dysfunction in pediatric BD such as Theory of Mind (ToM), which refers to the ability to reflect upon the mental states of self and others. However, there have been no studies to date that have examined the degree to which ToM deficits may vary across different subtypes of pediatric BD and whether or not they may be associated with disturbances in

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psychosocial functioning. This is particularly surprising given the significant functional impairments and interpersonal difficulties seen among pediatric BD patients, as well as the considerable variability in clinical presentation across subtypes. ToM, or the ability to understand what another person is thinking or feeling, is vital for successful communication and interpersonal functioning (Flavell, 1999; Tager-Flusberg and Sullivan, 2000). ToM deficits have been observed in a number of psychiatric disorders including autism spectrum disorders (see Baron-Cohen, 2000 for a review), schizophrenia (Corcoran and Frith, 1996; Frith and Corcoran, 1996; Greig et al., 2004; Schenkel et al., 2005), intellectual disabilities (Tager-Flusberg and Sullivan, 2000; Cornish et al., 2005), antisocial personality disorder (Richell et al., 2003; Dolan and Fullam, 2004), depression (Inoue et al., 2004), and BD (Kerr et al., 2003). Among adults with BD, ToM deficits have been observed in both symptomatic (Kerr et al., 2003; Wolf et al., 2010) and euthymic (Bora et al., 2005; Olley et al., 2005; Mahli et al., 2008; Montag et al., 2010) samples. However, the majority of ToM studies have focused on adult type I BD patients, and fewer studies have directly examined differences between type I versus type II patients. Findings have been somewhat inconsistent, with both type I and type II patients performing more poorly on complex mental state reasoning tasks, while only type I patients have been shown to perform more poorly on basic false belief and visual mental state decoding tasks (Bora et al., 2005; Montag et al., 2010; Martino et al., 2011). More impaired ToM ability among type I pediatric bipolar patients would be consistent with previous studies in both child and adult BD samples indicating greater cognitive and social

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Table 1 Demographic and clinical characteristics of the pediatric bipolar disorder I (BD I) and II (BD II) and healthy comparison (HC) subjects. Means, standard deviations (S.D.), percentages, and significance values are presented below.

Variables Age (years) Socioeconomic statusa YMRS CDRS-R WASI IQ

HC Mean (S.D.)

BD I Mean (S.D.)

BD II Mean (S.D.)

Analysis F(p)

12.44 (2.84) 1.68 (0.80) 3.36 (3.95) 20.04 (2.07) 111.16 (10.76)

11.35 (2.83) 2.00 (0.87) 17.47 (10.93) 33.50 (10.28) 106.41 (9.21)

13.38 (3.70) 1.38 (0.52) 7.00 (10.86) 31.88 (8.06) 104.63 (14.25)

1.39 (0.26) 1.85 (0.17) 15.43 ( o0.0001) 22.10 ( o 0.0001) 1.57 (0.22) χ2 (p) 4.61 (0.10)

N (%)

N (%)

N (%)

Sex Male Female

16 (64%) 9 (36%)

10 (59%) 7 (41%)

8 (100%) 0 (0%)

Race Caucasian Other

22 (88%) 3 (12%)

14 (82%) 4 (18%)

7 (88%) 1 (12%)

9 8 2

5 0 0

0.29 (0.87)

Comorbid diagnoses ADHDb Anxietyc ODDd a

Rated with Hollingshead Index of Social Position. Diagnosis of attention deficit hyperactivity disorder. Diagnosis of an anxiety disorder. d Diagnosis of oppositional defiant disorder. b c

cognitive dysfunctions among type I patients. For example, in pediatric and adult BD patients, more impaired attention, verbal learning and memory, and executive functioning have been documented among type I patients compared to type II patients and Healthy Controls (HC) (Torrent et al., 2006; Simonsen et al., 2008; Hsiao et al., 2009; Schenkel et al., 2012b). Additionally, compared to HC, greater impairments in working memory for emotional stimuli have also been documented among type I, but not type II pediatric bipolar patients (Schenkel et al., 2012a). In pediatric BD samples, there has only been one investigation of ToM ability, with symptomatic patients performing more poorly on ToM and social inference tasks (Schenkel et al., 2008b). Moreover, pediatric BD type I patients performed more poorly than controls and type II patients on measures of social inference, but there was no significant difference between bipolar patients on emotionally valenced first order false belief measures (Schenkel et al., 2008b). To date, little is known regarding the nature of ToM deficits in pediatric BD patients, and in particular whether or not they show a different pattern of dysfunction for emotional versus cognitive (non-emotional) ToM tasks. Additionally, there have been no systematic investigations that have examined differences between type I and type II patients on different types of ToM tasks and the extent to which ToM deficits are related to real world psychosocial difficulties. Therefore, the aim of this study was to investigate multiple aspects of ToM (e.g., cognitive, emotional, and perceptual) among type I and type II pediatric BD patients and to examine the extent to which impaired ToM performance is associated with psychosocial functioning difficulties. Specifically, we expected that pediatric patients with type I BD would perform more poorly on each of the ToM tasks than type II patients and HC, and that performance on these tasks would be related to real-world psychosocial dysfunction.

2. Method 2.1. Participants and procedure Participants consisted of 25 pediatric BD and 25 HC participants recruited from the community between the ages of 7 and 18 years (mean age¼ 11.23, S.D.¼2.78). Verbal or written assent was provided by all children in addition to the written informed consent by caregivers. The HC and pediatric BD groups were equal in age, sex (34

males), socio-economic status (SES), and intelligence as assessed by the 2-subtest version of the Wechsler Abbreviated Scale of Intelligence (WASI; Wechsler, 1999). Pediatric BD patients were diagnosed as having BD type I (n¼17), or type II (n¼ 8) based on the DSM-IV criteria (American Psychiatric Association, 2000) via the Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (KSADS-PL; Kaufman et al., 1997). Pediatric BD patients were recruited from a local outpatient psychiatry treatment program within an academic medical center specializing in the diagnosis and treatment of pediatric mood disorders located in the Northeastern United States. They were also recruited from a local support group for parents of bipolar children sponsored through the Depression and Bipolar Support Alliance (DBSA). Healthy comparison subjects were euthymic with Young Mania Rating Scale (YMRS; Young et al., 1978) scores of r 8 and Child Depression Rating Scale (CDRSR; Poznanski et al., 1985) scores of r 40. None of the participants in the healthy comparison group met DSM-IV criteria for any major psychiatric disorder (see Table 1 for demographic and clinical data). Exclusion criteria for all subjects were active substance abuse, an IQ lower than 70 on the WASI, serious medical conditions, history of a head injury, or diagnosis of an Autism Spectrum Disorder (ASD) based on the Social Communication Questionnaire (Rutter et al., 2003). This study was approved by the Institutional Review Board (IRB).

2.2. Measures 2.2.1. Symptomatology and clinical measures The Young Mania Rating Scale (YMRS; Young et al., 1978): The YMRS is a clinician-rated measure used to assess manic symptomatology. It consists of 11 questions that are scored on a scale of 0–4 (with four items scored 0–8). The YMRS has excellent psychometric properties for use with pediatric samples (Fristad et al., 1995; Youngstrom et al., 2002). The Children's Depression Rating Scale-Revised (CDRS-R, Poznanski et al., 1985; Poznanski and Mokros, 1996): The CDRS-R is a brief 17-item clinician-rated measure of depression severity with well-established reliability and validity (Poznanski et al., 1985; Poznanski and Mokros, 1996). Each item is rated on a scale of 1–5 (3 items) or 1–7 (14 items), with raw scores ranging from 17 to 113. The Social Communication Questionnaire-Lifetime Version (SCQ; Rutter et al., 2003): The SCQ is a parent/caregiver measure of ASD symptomatology appropriate for children over 4 years. It consists of 40 yes/no questions of various ASD symptoms/behaviors. Scores provide an index of symptom severity and indication of an ASD diagnosis ( Z 15 cutoff score). It has excellent discriminant validity and utility as an efficient screener for ASD, and has consistently demonstrated effectiveness in predicting ASD versus non-ASD status in multiple studies (Chandler et al., 2007; Wilkinson, 2011).

2.2.2. ToM measures The Revised Mind in the Eyes Test (MET; Baron-Cohen et al., 2001):The MET measures the ability to understand another person's mental state using 36 images of only the eye region of the face. It requires participants to utilize subtle perceptual

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cues to assess implicit mental states (i.e., what the person in the picture is thinking or feeling). Participants must choose one answer from four possible choices, and the total correct score is calculated. See the Appendix A for an example of the MET. The Cognitive and Emotional Perspective-Taking Task (CEPTT; Hynes et al., 2006). Focusing on the explicit cognitive–linguistic aspects of ToM, the CEPTT is a measure of emotional and non-emotional perspective-taking and false-belief. It consists of 28 written scenarios where participants are required to make an attribution to a character, 14 with an emotional valence—emotional perspective-taking (E-PT) and 14 without an emotional valence—cognitive perspective-taking (C-PT). See the Appendix A for C-PT and E-PT examples. 2.2.3. Social functioning measure The IPR (Klein et al.,1990): The IPR is a 25-item measure assessing problematic relationships with peers, and has been shown to have good psychometric properties (Klein et al., 1990). Child participants answer questions about the quality of their peer relationships (i.e., I get along very well with my peers), and questions are scored on a 7-point scale ranging from “none of the time” to “all of the time” with higher scores indicating a greater magnitude or severity of problems. 2.3. Data analysis To provide a standard metric for comparison across the ToM and psychosocial measures, MET, CEPTT, and IPR scores were standardized to z scores based on the means and standard deviations from the healthy comparison group (Herbener et al., 2005; Pavuluri et al., 2006; Schenkel et al., 2007). On the CEPTT, a 3  2 (diagnostic group  CEPTT condition) repeated measures ANOVA was conducted to examine group differences on the C-PT and E-PT conditions, with follow-up group comparison analyses using Tukey's honestly significant different (HSD) tests. Oneway ANOVA was used to examine group differences on the MET and the IPR with Tukey's HSD follow-up analyses. To control for unequal distributions of males and females in the BD type I and II groups on ToM performance, additional ANOVA analyses were done with gender as a covariate. Additionally, separate t-tests were conducted for the BD and HC groups to examine gender differences on the ToM measures. Correlational analyses were used to examine associations between CEPTT, MET, IPR, and symptom scores.

3. Results

group  condition interaction (F(2,47)¼5.78, po0.01). Overall, across the three groups, performance on the C-PT condition was poorer on average than performance on the E-PT condition, however, the three groups differed in their pattern of performance across conditions. Post-hoc Tukey's honestly significant different (HSD) tests indicated that overall, patients with BD type I performed more poorly than HCs on the CEPTT, (po0.005). There were no significant differences between type I and II BD patients or between type II BD patients and HCs (p's40.05). One-way independent ANOVAs were performed for each condition to break down the interaction. On the C-PT condition, there was a significant effect of group (F(2,47)¼7.97, p¼0.001), with type I BD patients performing more poorly on the C-PT condition than HC (p¼0.001). There were no significant differences in performance between patients with type I and type II BD, or between type II BD patients and HC (p's40.05). On the E-PT, there were no significant group differences (F(2,47)¼2.15, p¼ 0.13) (see Fig. 1 and Table 2). With gender added as a covariate (3  2 MANCOVA), there was a significant main effect of group (F(2,46) ¼ 7.35, p o 0.01) and a group  condition interaction (F(2,46) ¼ 5.77, po 0.01), and a trend toward a significant main effect of condition (F(1,46)¼ 3.75, p ¼0.06).

3.3. Group comparisons on the Mind in the Eyes Test (MET) On the MET, there was a significant group effect (F(2,47) ¼ 12.37, po 0.0001), with post-hoc follow-up analyses indicating that type I BD patients performed significantly more poorly than both type II patients (p o0.05) and HC (po 0.0001). There were no significant differences between type II BD patients and HC (p 40.05) (see Fig. 2). With gender added as a covariate, the group effect remained significant (F(2,46) ¼12.94, p o0.0001).

3.1. Demographic variables As expected, there were significant differences between the groups on the YMRS and CDRS-R. On the YMRS, pediatric BD type I patients exhibited greater manic symptoms compared to type II patients and HC, and on the CDRS-R both type I and II patients exhibited greater depressive symptomatology compared to HC. There were no significant differences between the groups on age, sex, SES, or IQ on the WASI (see Table 1). There were also no significant differences between males and females on any of the ToM tasks in either the BD or HC groups (p's40.05). In the BD group, 14 (56%) participants had a comorbid diagnosis of ADHD, 8 (32%) were diagnosed with an anxiety disorder, and 2 (8%) had a diagnosis of oppositional defiant disorder (ODD). Type I patients were significantly more likely to have a comorbid diagnosis than type II patients (χ2 ¼ 5.03, po0.05). This represents an odds ratio indicating that type I BD patients are 7.78 times more likely to have at least one comorbid diagnosis compared to type II BD patients. On average, type I patients also had a greater number of different types of comorbid diagnoses than type II patients (t(23) ¼2.68, p o0.05). Among children with BD, 23 (92%) were receiving pharmacotherapy, 43% of this group were receiving mood stabilizers (e.g., lithium, oxcarbazepine, divalproex, lamogrigine), and 61% were receiving atypical antipsychotics (e.g., risperidone, aripiprazole, quetiapine). Additionally, in the BD group, 6 patients and 5 mothers reported receiving psychosocial treatment.

3.4. Group comparisons on the IPR On the IPR, there was also a significant group effect (F(2,47)¼3.34, po 0.05). Post-hoc follow-up analyses indicated that type I BD patients reported more problematic peer functioning than HC (p o0.05). There were no significant group differences between type I and II BD patients or between type II BD patients and HC (p 40.05) ( see Fig. 3).

3.2. Group comparisons on the CEPTT On the CEPTT, a 3 (group)  2 (condition) ANOVA indicated a significant main effect of diagnostic group (F(2,47)¼6.88, po0.005) and CEPTT condition (F(1,47)¼12.23, p¼0.001), and a significant

Fig. 1. z Scores on the cognitive and emotional components of the Cognitive and Emotional Perspective-Taking Task (CEPTT) for the Pediatric Bipolar Disorder (PBD) and Healthy Control (HC) groups. Higher scores indicate more correct responses.

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Table 2 Means, standard deviations (S.D.), and group comparisons on the Cognitive and Emotional Perspective-Taking Task (CEPTT), the Mind in the Eyes Task (MET) and the Index of Peer Relations (IPR) for healthy comparison (HC) and pediatric bipolar disorder I (BDI) and II (BDII) subjects. Average z scores for correct responses are presented. HC Mean (S.D.)

BD I Mean (S.D.)

BD II Mean (S.D.)

Group comparisons

CEPTT Cognitive

0.00 (0.98)

 2.76 (3.06)

 1.72 (2.98)

Emotional

0.00 (0.98)

 0.78 (1.28)

 0.59 (1.86)

HC4BD Innn HC¼BD II BD I ¼ BD II HC¼BD I HC¼BD II BD I ¼ BD II

MET

0.00 (1.00)

 1.68 (0.98)

 0.52 (1.48)

IPR

0.00 (1.00)

0.93 (1.63)

0.75 (0.46)

HC4BD Innn HC¼BD II BD I o BD IIn HCo BD In HC¼BD II BD I ¼ BD II

Note. On the IPR, higher scores indicate more problematic interpersonal functioning. t¼ o 0.1 nn p o 0.01. n

po 0.05. p o 0.001.

nnn

Fig. 2. z Scores for the Pediatric Bipolar Disorder (PBD) and Healthy Control (HC) groups on the Revised Mind in the Eyes Task. Higher scores indicate more correct responses.

Fig. 3. z Scores for Parents and Children on the Index of Peer Relationships (IPR) for the Pediatric Bipolar Disorder (PBD) and Healthy Control (HC) groups. Higher scores indicate more problematic peer functioning.

3.5. Associations between psychosocial, ToM, and symptom measures

distinct types of measures, each aimed at assessing a specific construct of ToM: perceptual mental state decoding (MET), inferring what another individual is thinking (C-PT), and inferring what another individual is feeling (E-PT).

Among both type I and II BD patients, more problematic peer relationships on the IPR were significantly associated with poorer performance on both the C-PT (r ¼  0.45, p o0.05) and E-PT tasks (r ¼  0.42, p ¼0.05), however, IPR scores were not significantly associated with MET scores (r ¼  0.18, p ¼ .39). Among BD patients, increased symptoms of mania on the YMRS were associated with poorer performance on the MET (r ¼  0.43, p o0.05). There were no other significant associations.

4. Discussion This is the first study to systematically investigate multiple aspects of ToM functioning in type I versus type II pediatric BD patients, and the degree to which ToM deficits are associated with impairments in real-world psychosocial functioning. To probe potential variations in the profiles of ToM dysfunction among different bipolar patient groups, this investigation employed three

4.1. ToM and interpersonal functioning among Type I versus Type II pediatric BD patients As expected, findings from this study indicate that type I BD youth evidence significant ToM impairments and more problematic peer relationships compared to HC, and suggest therefore, that a more severe form of the disorder is associated with greater interpersonal and social-cognitive dysfunctions. Findings from this study are consistent with the adult literature reporting greater ToM impairment among type I patients, particularly on perceptual measures (e.g., MET) and false-belief tasks (Bora et al., 2005; Montag et al., 2010; Wolf et al., 2010). Specifically, type I pediatric BD patients in this study evidenced disturbances in the ability to decode another's mental state based on observable physical information beyond the six basic emotions (i.e., MET), as well as on a task that required the ability to integrate verbally-mediated

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social cues and contextual information to understand and predict another's behavior (i.e., CEPTT) (Tager-Flusberg and Sullivan, 2000; Sabbagh, 2004; Martino et al., 2011). Therefore, type I bipolar patients in this study appear to evidence deficits in basic perceptual mental state decoding, as well as with more complex language-based mental state understanding and interpretation. 4.2. ToM predictors of psychosocial functioning Among bipolar youth only, poorer performance on both the cognitive and emotional conditions of the CEPTT was associated with more impaired psychosocial functioning with peers on the IPR. Findings highlight the importance of being able to correctly identify and understand another individual's thoughts and intentions, as well as their feelings, for successful social interaction. Interestingly, performance on the MET was not associated with poorer peer functioning on the IPR. The MET requires significantly more implicit mental state decoding, and is therefore largely independent of language ability (Tager-Flusberg, 2001), while the CEPTT requires the integration of explicit social knowledge and contextual information, and is therefore more language dependent. Given the significant language demands required for successful interpersonal communication, it is not surprising that we found a significant relationship between reports of greater peer difficulties on the IPR and poorer performance on the CEPTT. Additionally, the CEPTT is a more socially-based measure of ToM than the MET, and therefore, may be a more ecologically valid indicator of real-world mentalizing ability and a better predictor of actual psychosocial functioning. It may be the case that perceptual mental state decoding, characteristic of the MET, is less important for successful interpersonal functioning than verbally-mediated social reasoning, characteristic of the CEPTT. 4.3. Emotional versus cognitive ToM on the CEPTT Interestingly, we did not find a significant difference between type I BD patients and HC on the E-PT task (an emotional mentalizing task) as would have been expected, and this lack of a significant finding was somewhat surprising. However, past studies of ToM among adult patients with BD have reported similar findings. In particular, adult studies of ToM have reported greater impairments among BD patients on cognitive, but not emotional ToM tasks (Shamay-Tsoory et al., 2009; Montag et al., 2010). These findings suggest that there may be separate mechanisms for inferring thoughts from those involved with inferring emotions, and the former may be more specific to BD. There are also a number of other alternative explanations for this negative finding. The emotional condition (E-PT) of the CEPTT required first-order mental state understanding and empathy (e.g., identifying how a character might feel in a given social situation), while the cognitive (C-PT) condition required more advanced mental state reasoning and false-belief understanding (e.g., understanding how one character might be tricked into believing something that is false based on information from another character). The discrepancy in the degree of complexity and language-demand between the two tasks may have, in part, accounted for the difference in performance. The C-PT condition required a greater degree of non-literal (and therefore more abstract) verbal reasoning skill compared to the E-PT condition which required more straight forward empathic ability. An alternate hypothesis might be that the emotional aspect of the E-PT was more engaging for BD patients, and therefore, was more effective in holding their attention during the task and aiding in task performance. Additional studies that examine this issue more directly using a broader array of ToM tasks in addition to measures of attention and comprehension are warranted.

The lack of a significant group differences on the E-PT condition is inconsistent with a previous investigation documenting more impaired ToM ability among pediatric BD patients in affectively charged contexts (Schenkel et al., 2008b). Discrepancies between the two investigations may be due to differences in the types of ToM tasks used. The Schenkel et al. (2008b) investigation examined the extent to which differences in emotional valence interfered with adequate false belief reasoning (false belief understanding within the context of negative, positive, and neutral social scenarios), while the present study investigated first-order mental state understanding (or the ability to identify a characters emotional state). Therefore, it could be that type I bipolar youth shows difficulty on false-belief mental state reasoning tasks, and this impairment becomes exacerbated in the face of emotional challenge. However, it is important to note that these interpretations are somewhat speculative. Future studies of empathy, as well as cognitive and emotional false belief understanding, perspective-taking, and social inference are needed to better understand ToM impairments in pediatric BD patients. Furthermore, studies should incorporate neurocognitive measures (e.g., attention, working memory, verbal learning and memory, and executive functioning) in addition to ToM tasks to better tease out the influence of cognition with respect to ToM impairments among pediatric BD patients. 4.4. Limitations There are a number of important limitations to the present investigation. This study utilized a relatively small sample size and findings should be interpreted with caution. Also, the BD type II group was quite small and gender biased with only male participants. Because of this, results cannot be generalized to both male and female type II BD patients. Larger studies, with an equal number of males and females, are needed to further examine possible differences in ToM between differing BD subtypes. In addition, the majority of patients were medicated and in varying clinical states, and were therefore receiving different classes of medications (atypicals, mood stabilizers, or both). Psychotropic medications have been shown to affect ToM functioning in psychiatric patients, (Montag et al., 2010) and therefore the degree to which medication may have affected performance among type I patients is unclear. The limited sample size in this study did not allow for a systematic examination of the effects of psychotropic medications on ToM functioning among type I versus type II patients, however, this should be a point of investigation for future studies. Lastly, ADHD symptomatology and attention were not specifically controlled. It is unclear to what extent attentional difficulties may have played a role in the group differences seen on the ToM tasks. It is important to note that there were no significant group differences on the emotional condition (E-PT) of the CEPTT, where there were significant group differences between BD type I patients and HC on the cognitive condition (C-PT). If attentional difficulties were associated with task performance, it is unclear why they would differentially influence cognitive perspective-taking as opposed to emotional perspective-taking ability. Additional investigations are needed to more systematically examine ToM abilities among BD youth, including those that control for comorbid psychopathology as well as attentional impairments. 4.5. Clinical Implications This investigation is an important first-step toward clarifying the nature of both perceptual and verbally-mediated ToM impairments among pediatric BD patients and their link to real-world psychosocial functional impairments. Difficulties in the ability to identify and understand the mental states of others can result in the misreading of social cues, resulting in a reduced ability to accurately comprehend social interactions. This, in turn, would

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increase the potential for more negative and misguided interactional patterns with others, greater stress, and increased risk for relapse and negative outcomes (Keenan-Miller and Miklowitz, 2011). As such, psychosocial treatments should target more basic perceptual mental state decoding strategies, including exercises in attending to and accurately identifying subtle facial cues, particularly within the eye region where the majority of social information is conveyed (Emery, 2000). Additionally, treatments should also address more complex language-based perspective-taking ability, including exercises in correctly identifying and responding to both subtle and direct social cues. This study found a significant association between ToM impairments and child reports of greater interpersonal difficulties and problematic relationships with peers. However, the actual nature of these psychosocial difficulties, including the ways in which they are specifically related to ToM impairments, is in need of further investigation. For example, it remains unclear whether or not maladaptive social behaviors among pediatric BD patients are the direct result of a misidentification of social cues and are therefore causal in nature. In addition, it remains to be seen whether or not other aspects of interpersonal functioning, such as problematic relationships with family members and/or parents are also associated with ToM impairments. A better understanding of the underlying dynamics of psychosocial dysfunction in pediatric BD can help clinicians continue to tailor effective treatment and intervention programs for pediatric BD patients. Early identification and intervention strategies can facilitate the development of more effective interpersonal skills, thereby reducing social stressors and increasing support from peers and family members, and facilitating better clinical outcomes.

Appendix A The “Reading the Mind in the Eyes” Test Revised Version (MET) example The four choices presented with this expression are reflective (correct), aghast, irritated, and impatient (see Fig. A1) Cognitive Perspective-Taking Example (C-PT) Simon is a big liar. Jim knows this. Simon stole Jim's baseball bat, and Jim confronts him saying: "Where is my baseball bat? You must have hidden it either in the cupboard or under your bed, because I have looked everywhere else. Where is it?" Simon tells Jim the bat is under his bed. Why will Jim look for the bat in the cupboard? 1) Jim suspects it would not fit under Simon's bed. 2) Jim knows it will be in the cupboard because Simon said it was under the bed. 3) Jim thought it was in the cupboard anyway.

Emotional Perspective-Taking example (E-PT) Ruth is in a hurry, and she is driving away from Debbie's place when Debbie's cat runs suddenly into the road. She hits the brakes, but feels her car go over something. She stops and checks to see whether she has killed the cat. She finds that she ran over a bump in the road, and that the cat is safely on the other side of the road. How does Ruth feel?

745

Fig. A1

1) Ruth feels relieved that she did not kill that cat. 2) Having stopped that car makes Ruth feel anxious. 3) Because the cat survived, Ruth is angry.

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