RECOGNITION OF EMOTIONS AND AFFECTIVE ATTITUDES IN CHILDREN WITH ATTENTION-DEFICIT HYPERACTIVITY DISORDER We, the undersigned, hereby declare no conflict of interest exists in relatio tot eh paper called „RECOGNITION OF EMOTIONS AND AFFECTIVE ATTITUDES IN CHILDREN WITH ATTENTION-DEFICIT HYPERACTIVITY DISORDER“

Background/Aim. Introduction and Children with attention-deficit 
 hyperactivity disorder (ADHD) show lower degree of recognition of their own 
 emotions and greater behavioral difficulties than children who do not have 
 this disorder. This also affects the recognition of other people's emotions 
 that are expressed not only by their language content, but also by their 
 facial expression and the way they express the emotional message through 
 speech. The aim of this study was to examine how children with ADHD 
 recognize emotions in speech (joy, anger, fear, sadness) and affective 
 attitudes (threat and commandment) in relation to children of typical 
 development. Most research in this area focuses on recognizing emotions 
 based on facial expressions rather than on emotions in speech. Methods. The 
 study included 31 children with ADHD and 29 typical developmental children 
 aged 6 to 13 years. To assess the ability to recognize emotions and 
 affective attitudes, a corpus of Speech Emotional Expression and Attitudes 
 (GEES - Korpus za procenu Govorne emocionalne ekspresije i stavova) was 
 used. This corps included sentences that expressed emotions of anger, joy, 
 fear, and sadness, and from affective attitudes, threat and command. Results 
 and Conclusion. The results obtained show that children with ADHD have worse 
 recognition of emotions and affective attitudes in speech than children of 
 typical development (t = 8.81; p = 0.000). Joy is the only emotion where no 
 statistically significant difference was found. In all other emotions and 
 affective attitudes, a difference exists and is statistically significant 
 (p<0.01). Also, the results showed that there was a statistically 
 significant association between age and recognition of emotion and affective 
 attitudes in both groups, but this association was more pronounced in 
 children of typical development. The results of this study provided 
 important clues about the perception of emotions and affective attitudes in 
 speech in children with ADHD. These results are very important for the 
 conception of therapeutic procedures, especially in the development of 
 strategies for modeling the behavior of children with ADHD. [Project of the 
 Serbian Ministry of Education, Science and Technological Development, Grant 
 no. 179055: Effects of cochlear implantation on education of deaf and 
 hearing impaired individuals]


Introduction
Attention Deficit Hyperactivity Disorder is diagnosed in childhood or adolescence and is characterized by three groups of persistent symptoms: hyperactivity, attention deficit and impulsiveness 1 . In addition, children with ADHD can have a number of comorbid externalizing and internalizing psychiatric conditions such as anger, aggression, behavioral disorders, delaying responsibilities, anxiety, depression, guilt 2 . ADHD affects optimal children's development, their self-esteem, weakens social contacts with parents and teachers 3,4 , but it also affects the occurrence of school skills difficulties and academic failure 5,6 . Worldwide prevalence of ADHD ranges from 5 to 7% 7,8 . The high prevalence of this disorder has attracted a great deal of attention from researchers and clinicians trying to 5 understand the causes and mechanisms leading to the onset of characteristic symptoms of ADHD, as well as finding the best therapy for it. ADHD is believed to be a neurobehavioral developmental disorder but its pathophysiology is not yet fully known. So far, the investigated causes of ADHD can be classified into two categories: environmental and molecular-genetic. In the category of environmental causes, those arising from obstetric complications 9 , fetal or infantile exposure to various agents 10 , as well as the conditions in which children grow and develop, have been studied [11][12][13] . Molecular genetic causes have been extensively investigated in the field of dopamine transmission 14 , or catecholaminergic dysregulation 15 .
Studies conducted in recent years show that children with ADHD have specific social deficits such as: poor recognition of role-playing behaviors, inflexibility in responses, inability to modify their own behavior in response to changes in environmental demands, and unconscious subtle, but very important social cues [16][17][18] . Research findings up til today, suggest that impaired social skills and present behavioral problems in children and adolescents with ADHD are not fully explained by additional comorbidities or secondary consequences in the form of executive function deficits [19][20][21] . A number of authors believe that answers related to social skills disorders and behavior in children and adolescents with ADHD can be found in understanding possible deficits in emotion recognition. Studying the emotional competence of children with ADHD can be an important complement to these children's social skills research. In order for children to engage in appropriate social interactions, they must be able to recognize and make judgments about the emotions of others. The ability to interpret and respond appropriately to the emotions of others is crucial for interpersonal interactions. Evidence to support this finding can be found in studies of the social functioning of children with autism and their poor recognition and processing of emotions 22 . Based on this, it can be assumed that in children with ADHD there is an association between poor social skills and difficulties in recognizing emotions.
Research to date has shown that children with ADHD show poorer results in recognizing facial emotions than the typical population 17,23,24 . For these children, tasks that required the interpretation of emotional cues from face photos were difficult and they made more mistakes in those tasks than the typical population 25 . Also, it was difficult for children and adolescents with ADHD to reconcile the primary emotion face expression with the 6 emotional message of the story read to them 26 . There is evidence that children with ADHD were less successful in recognizing their own emotions 27 .
It is important to note that most of the research performed so far, has been examining the recognition of facial emotions and contextual cues in children with ADHD. The general impression is that there is no research related to recognizing emotions in the voice.
Through research done on typical developmental children, it has been concluded that the emotional properties of vocal cues can influence the infant's focus on objects and the exploratory behavior of the world [28][29][30] . Typical developmental children have been shown to be able to accurately classify prosody as joy or sadness at a very young age 31 . A survey of typical developmental children aged 5 to 10 years has shown that children as young as five are able to easily and accurately recognize and interpret a range of emotional cues from the voice 32 . Also, this research has shown that there is improvement in results with advancing age. There is a very interesting study comparing the recognition of emotions on the basis of visual (facial expressions), auditory (speech) and audio-visual (facial expressions and speech) modalities of information transmission. Children between the ages of 5 and 18 were exposed to: only auditory, only visual or audio-visual modalities of parent-child communication. For younger children (up to 8 years), the auditory canal was more important than the visual. Older children, on the other hand, relied more on visual cues 33 .
In their interactions with others, children, just like adults, need to interpret a wide range of social signals to understand the intentions and feelings of others. The ability to distinguish social signals is thought to develop very early, as early as about the fifth month of life. Babies at that age are able to respond to approvals and bans 34 , even when spoken in an unfamiliar language 35 . These discriminations can be made on the basis of differences in lower cognitive stimulus classes, such as Fo's height, while connecting auditory cues to social circumstances and events require more sophisticated cognitive abilities 36  The aim of the study was to evaluate the ability to recognize emotions and affective orders in speech, and to examine whether there were differences in their recognition in children with ADHD compared to typical population children. It has been hypothesized that children with ADHD perform worse in recognizing emotions and affective speech orders than the typical population, that there is a difference in the ability to recognize different types of emotions and affective speech orders in this population of children.

Methods
The research was approved by the Academic Council and Ethics Committee of the At the time of testing, children with ADHD did not use pharmacotherapy, and the rehabilitation program they attended included metacognitive strategies, psychomotor reeducation, neurofeedback training, and sports and recreational therapy.
The criteria for determining whether children would be included in the sample of this study were as follows: children had no other disorders or disorders, no other neurological or psychiatric illnesses, did not use pharmacological therapy, all children on the Raven 8 matrices had scores above 80 and all children on the SNAP IV scale had over 70% expression of combined type ADHD symptoms. The experimental group was selected from the population of children who, due to ADHD, were included in the rehabilitation program of the Speech Therapy Cabinet "Plećević". The control group also met the above criteria (except those related to the severity of ADHD) and was selected from a population of children who attended regular schools and were never included in defectology or speech therapy programs.
Assessment of emotion recognition and affective attitudes was performed using the Speech Emotional Expression and Attitude Assessment Corps (GEES) 37  and affective attitudes were scored with 1 point, so the maximum score for each task group was 3 points and the maximum total score for GEES was 18 points. Inaccurate answers and no responses were scored with 0 points, so the minimum score could be 0 points for each task group and also for the total score at GEES. The test was performed during one encounter and the children were presented with the pronunciation of selected sentences in a randomized schedule. The task was for the children to recognize the emotion and affective attitude in the spoken manterial, without paying attention to the linguistic content, and to verbalize their observations. To help them, they were provided with a list of selected emotions in writing. The recorded material was presented using computer equipment and the participants used headphones. Children were expected to respond within 300 to 6000 ms and the next task was set 1200 ms after the registered response. If no responce was given, it is automatically switched to the next task. The GEES internal consistency was good (α = 0.831).

9
The study involved 60 children, which were divided into two groups: 31 children with ADHD (51.7%) and 29 typical population children (48.3%). The children ranged in age from 6 to 13 years (AS ± SD = 9.25 ± 1.97). Based on the T test for independent samples, it was concluded that the two groups did not differ significantly in terms of age (t (58) = -0.974, p = 0.332). There were 51 boys (85%) and 9 girls (15%) in relation to gender in the sample. The T test for two independent samples showed no statistically significant difference with respect to gender (t (58) = 1.913, p = 0.061). Speech and language assessment was performed prior to the GEES examination and the results showed that children from the two observed groups did not differ statistically in terms of achievement (t (58) = 0.942, p = 0.327).
Descriptive statistics, 95% confidence interval, effect size (Cohen's d), T test for independent samples, T test for dependent samples and Pearson's correlation coefficient were used in the analysis of the results. Statistical analysis was performed using the IBM SPSS 25 software package. Table 1 shows the arithmetic mean, standard deviation, and 95% confidence interval and statistical significance of differences in arithmetic means for recognizing emotions and affective speech orders in ADHD and the typical population. Children with ADHD best recognized joy and typical children sadness. The affective threat order was the least recognized in children with ADHD and in the typical population of fear emotions and the affective command order. (Table 1) To determine statistically significant differences in the results of emotion and affective speech orders recognition between the two observed groups, a T test for two independent samples was used. The typical population of children was better in recognizing most emotions and affective orders with a statistically highly significant difference (p <0.01) than children with ADHD, except for the joy emotion, where statistical significance was not established. Based on the analyzed effect size (Cohen's d) for all statistically significant differences found in recognizing emotions and affective orders, it can be concluded that there is a large difference effect for emotions fear (d = 1.13), sadness (d = 1.23) and anger (d = 1.42) as well as for affective orders threat (d = 2.01) and command (d = 0.98). The effect size for the overall results was also large (d = 2.28).

Results
To determine whether there were differences in the recognition of different emotions and affective orders in speech, a T test for dependent samples was used and this type of analysis was done separately for both populations of participants (Table 2). (Table 2) The results presented in Table 2 indicate that children with ADHD recognize emotions and affective orders with different success, whereas this is not the case with the typical population. Children with ADHD emotion have a statistically significant better recognition of joy than all other emotions and affective orders, and the statistical significance of differences also appears in fear -threat and sadness -threat. The children of the typical population differently recognized only the emotion of sadness in relation to the affective command order. It was interesting to compare the performance between emotion recognition versus affective orders, as shown in Table 2. Both groups of children had statistically significant higher recognition of emotions than affective accounts. This work also examines the association between age and recognition of emotions and affective speech orders in children with ADHD and children of typical development.
Pearson's correlation coefficient and confidence interval for linear correlation were used for this analysis. In children with ADHD, a mean association between age and command Differences were observed in quantitative indicators but also in structure because the typical population children were most sensitive to recognizing sadness, then joy, threat, anger and least sensitive to recognizing fear and command. ADHD children best recognized joy and then sadness, fear, command, anger and threat was worst. The only emotion in speech that children with ADHD recognize similarly to children of the typical population is joy (positive emotion) and there was no significant difference. Similar results were obtained by Shapiro et all who used an alternative model of emotion representation, that is, tasks related to recognizing emotions from the face and in prosody 38 . The results of their study showed that children with ADHD were less likely to recognize emotion in prosody and in cross-modal tasks where they were required to match that emotion with the appropriate facial expression. In the face recognition tasks, children with ADHD achieved very similar results to those of the typical population 38

. Corbett and
Glidden also found in their study mild to moderate difficulties in recognizing emotions in prosody, which, based of this, supported the thesis that the right cerbral hemisphere correlates with the emotion recognition deficit [39][40][41] .
Children with ADHD were significantly more likely to recognize joy over all other emotions and in relation to threat and command. A significant difference was still present in the better recognition of the fear and sadness in relation to the threat. In the typical population, a significant difference appeared only in the better recognition of sadness in relation to the command, while all other emotions and affective attitude threat were equally well recognized. Most studies that dealt with emotion recognition support the result of this research, which indicates that positive emotions are better recognized than negative ones in children with ADHD 17,23,42 . Some authors explain this difference in recognition of different emotions by deficits in verbal and non-verbal attention, which may contribute to incorrect or incompletely processed labels of speech stimuli. Based on their opinion, children with ADHD generally pay attention to the most prominent features of speech impulse from the environment, while subtle information does not come into their focus and thus remain unrecognized 39. However, the question arises as to why children with ADHD successfully recognize joy (positive emotion) rather than, for example, anger (negative emotion), although both emotions are strong and usually emphasized through speech prosody. These results cannot be fully explained by attention deficit such as brevity, selectivity, poor focus etc.
Consideration should also be given to the possible altered patterns and mechanisms of processing the emotional cues in speech primarily due to the lack of recognition of its own anger and fear 43 or as a result of unconsciously ignoring such emotions. This interpretation can be substantiated by the result that children with ADHD were the least sensitive in recognizing anger, and threats, which, despite carrying a strong message, remain poorly recognized.
Interestingly, emotions were better recognized than affective attitudes in both groups of children. This is important information for all significant persons from the child's environment: parents, educators, teachers as well as professionals involved in the treatment and rehabilitation of children with ADHD. Affective attitudes are usually used to warn of the danger, inhibition, interruption or to control children's negative behavior. The command and threat are clearly not adequate speech patterns through which the child can recognize the information conveyed to them from the environment. This is an important finding that needs to be considered in an educational and therapeutic context when it comes to determining approaches for working with this population of children.
The association between age and recognition of emotion and affective attitudes was much more pronounced in the typical population than in children with ADHD. In this study, growing up has been shown to improve overall outcomes, overall affective attitudes, 13 and command recognition. However, this influence was not recorded on the individual emotion recognition results as in the typical population. This means that with age, children with ADHD have not made significant progress in recognizing individual emotions in speech, but significant improvement has been observed in recognizing threat and command. Children with age seem to learn patterns of behavior that stem from command and threats, but they still do not rely on the trully recognized and experienced emotions that underlie those affective attitudes (such as anger, fear). It would be very interesting to focus future research on exploring the relationship between primary emotions and affective attitudes, as well as exploring mechanisms for recognizing and understanding affective attitudes in children with ADHD.
The limitations of this research are related to a relatively small sample, especially when it comes to the population of girls. Also, a dilemma was raised regarding the language corpus, which was filmed with actors and objectively represented the played emotional roles. It is certain that real situations would give a better emotional expression, but this is questionable approach since it touches the intimacy of the people who would be filmed.

Conclusion
Hyperactivity, impulsivity, and attention deficit disorder are certainly key factors contributing to the difficulties of children with ADHD. However, the results of this study suggest that deficits in understanding the emotional information may also be another critical factor affecting the problems that occur in the daily functioning of children with ADHD. One consequence of these difficulties is the avoidance or inappropriate response to social situations that require recognition of emotional information. Also, understanding and accepting the fact that children with ADHD have objective impediments to the processing of emotional voice messages and affective orders will contribute to better acceptance of these children by loved ones by the environment as well as by the professionals involved in the treatment and education of these children.