RESEARCH ARTICLE

Cool Executive Function and Verbal Comprehension Mediate the

Relation of Hot Executive Function and Theory of Mind in Children
with Autism Spectrum Disorder
Yen-Ting Yu , Hsing-Jung Li, Ching-Hong Tsai, Chien-Ho Lin, Szu-Shen Lai, and Kuan-Lin Chen

Impaired executive function (EF), verbal comprehension, and theory of mind (ToM) may contribute to social difficulties
in children with autism spectrum disorder (ASD). The linkage between cool (cognitive) EF and ToM has been widely
investigated, but the relations between hot (affective) EF and ToM remain largely unknown. The roles of cool EF and ver-
bal comprehension have not been previously explored together to address hot EF–ToM relations. This study applied
mediation analysis to investigate the mediating effects of cool EF and verbal comprehension to further elaborate the link
between hot EF and ToM in children with ASD and average intellectual abilities. A total of 97 children with ASD aged
from 6 to 12 years participated in this study. Children’s cool EF, hot EF, and verbal comprehension were, respectively,
measured with the computerized Dimensional Change Card Sort task, Children’s Gambling Task, and the verbal compre-
hension index of the Wechsler Intelligence Scale for Children-fourth edition. Children’s ToM was assessed with the The-
ory of Mind Task Battery. Partial correlation coefficients indicated that hot EF was significantly related with ToM with age
controlled for. The results of the mediation analysis showed that cool EF and verbal comprehension mediated the linkage
between hot EF and ToM. These findings highlight not only the connections between hot EF and ToM but also the
importance of cool EF and verbal comprehension on hot EF–ToM relations in clinical assessments and interventions for
school-aged children with ASD and average intellectual abilities. Autism Res 2020, 00: 1–11. © 2020 International Soci-
ety for Autism Research and Wiley Periodicals LLC

Lay Summary: Relatively few studies have investigated the hot (affective) executive function (EF)–theory of mind (ToM)
relations in children with autism spectrum disorder (ASD). This study discovered that hot EF was significantly related to
ToM, while cool (cognitive) EF and verbal comprehension mediated the relationship between hot EF and ToM. Therefore,
the influence of cool EF and verbal comprehension on hot EF–ToM relations should be considered in studies involving
children with ASD.

Keywords: autism spectrum disorder; executive functions; theory of mind; verbal comprehension

Introduction comprehension and inference of the mental states of others

[Hale & Tager-Flusberg, 2005]. They may incorrectly receive
Autism spectrum disorder (ASD) is a multifaceted neuro- social information from others and then inappropriately
developmental disorder characterized by impaired social respond to their social partners. In addition, their poor
communication and interaction, as well as restricted/ affective control, inflexible thinking, and inflexible behav-
repetitive behaviors and interests, which may affect daily ioral patterns also make their social difficulties worse
social functioning for one’s entire life (Diagnostic and [Lewis & Carpendale, 2009]. For example, they may have
Statistical Manual of Mental Disorders-fifth edition, DSM- emotional outbursts or become anxious/angry in unstruc-
5) [American Psychiatric Association, 2013]. The social tured and unpredictable social situations. Thus, these social
difficulties of children with ASD, such as difficulty in initi- difficulties have been proposed to be linked to their
ating and maintaining reciprocal conversations and inter- impaired theory of mind (ToM), executive functions (EF),
actions, have found been to be related to their poor verbal and verbal comprehension.

From the School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan (R.O.C.) (Y.-T.Y.); Department of Occupa-
tional Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan (R.O.C.) (Y.-T.Y., K.-L.C.); Department of Child and Adolescent
Psychiatry, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan (R.O.C.) (H.-J.L., C.-H.T.); Department of Psychiatry, Chi Mei Medi-
cal Center, Tainan, Taiwan (R.O.C.) (C.-H.L.); Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Taoyuan, Taiwan
(R.O.C.) (S.-S.L.); Institute of Allied Health Sciences, National Cheng Kung University, Tainan, Taiwan (R.O.C.) (K.-L.C.); Department of Physical Medi-
cine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (R.O.C.)
(K.-L.C.)
Received March 11, 2020; accepted for publication September 29, 2020
Address for correspondence and reprints: Kuan-Lin Chen, Department of Occupational Therapy, College of Medicine, National Cheng Kung Univer-
sity, No. 1 University Road, Tainan City 701, Taiwan (R.O.C.). E-mail: [email protected]
Published online 00 Month 2020 in Wiley Online Library (wileyonlinelibrary.com)
DOI: 10.1002/aur.2412
© 2020 International Society for Autism Research and Wiley Periodicals LLC

INSAR Autism Research 000: 1–11, 2020 1

Impaired Theory of Mind Related to Social Deficits in Children 2018; Mussey, Travers, Klinger, & Klinger, 2015], which
with ASD increases their social challenges [McEvoy, Rogers, &
Pennington, 1993; Moriguchi, 2014]. For example,
ToM is a multifaceted ability to infer the mental states of regarding the cool EF deficit, children with ASD who have
self and others, and further to predict and interpret poor flexibility have difficulty shifting topics and keeping
others’ behaviors [Premack & Woodruff, 1978]. However, up with dynamic conversations. They may easily break
children with ASD have been found to have either the reciprocity with their conversational partners in a
delayed or deviant developmental trajectories of ToM social context. Regarding the hot EF deficit, children with
[Burack & Volkmar, 1992; Peterson, Wellman, & Liu, 2005; ASD who have poor emotional regulation easily show
Pino et al., 2017]. For example, children with ASD master intense emotional responses to frustrations in challeng-
basic ToM skills (e.g., first-order false belief) much later or ing tasks. Thus, they may have difficulty cooperating
achieve lower levels of ToM knowledge than their typi- within a team and fail to have mature friendships in a
cally developing (TD) peers do [Fisher & Happé, 2005; social group. Therefore, EF deficits have been applied to
Happé, 1994a; Serra, Loth, Van Geert, Hurkens, & explain the odd and rigid social interactions of children
Minderaa, 2002]. Their ToM developmental trajectories with ASD.
are not in sequence and thus vary across individuals
[Peterson et al., 2005]. The ToM Hypothesis suggests that
impaired ToM could be the core cognitive deficit causing Verbal Comprehension and Social Deficits in Children
failures in social interaction and communication in chil- with ASD
dren with ASD [Baron-Cohen, 1992, 1997; Baron-Cohen, Verbal comprehension is also a key to successful interac-
Leslie, & Frith, 1985]. The delayed or deviant develop- tion in daily life. Children with ASD have been found to
ment of ToM impedes children with ASD in understand- show diverse deficits in verbal comprehension ability
ing and interacting with their social partners even in [Chan, Cheung, Leung, Cheung, & Cheung, 2005]. Some
daily activities [Peterson, Slaughter, & Paynter, 2007]. As children with ASD cannot comprehend representations
a result, children with ASD are more likely to have lower at the single-word level [Lucas & Norbury, 2014].
peer acceptance and develop fewer mutual friendships Although some demonstrate similar vocabulary and
[Caputi, Lecce, Pagnin, & Banerjee, 2012; Fink, Begeer, grammar comprehension to their cognitively controlled
Peterson, Slaughter, & de Rosnay, 2015], leading to peers, they are still poor in comprehending the main
greater frustration with social experiences and social iso- ideas, details, and inferences of conversations [Åsberg,
lation across their lifespans. Hence, the impaired ToM in 2010]. Consequently, children with ASD show difficulties
children with ASD may contribute to their social in following directions, understanding routines, and
challenges. understanding social-related information, and these diffi-
culties interfere in their social interactions with others.
EF and Social Deficits in Children with ASD Verbal comprehension, in addition to ToM and EF, is
another important factor in the social deficits of children
EF refers to a set of goal-directed cognitive skills for prob- with ASD.
lem solving, self-organization, and appropriate social
interaction [Baumeister, Schmeichel, & Vohs, 2007; The Relations among Hot EF, Cool EF, Verbal
Moriguchi, 2014; Zelazo, Carter, Reznick, & Frye, 1997]. Comprehension, and ToM
Two different types of EF, “cool/cognitive” and “hot/
affective” EF, were first proposed by Metcalfe and Mis- The links within hot EF, cool EF, verbal comprehension,
chel [1999]. Cool/cognitive EF refers to the EF in and ToM have been addressed in the previous literature.
decontextualized, abstract, and logic-based contexts, such First, hot EF is influenced by cool EF. Metcalfe and Mis-
as inhibition, working memory, flexibility, and planning chel [1999] proposed the hot–cool system to indicate that
[Elliott, 2003; Qu & Zelazo, 2007; Zelazo & Carlson, cool EF can be activated by hot EF, and then cool EF may
2012]. In contrast to cool EF, hot/affective EF refers to the mediate the process of hot EF. Zelazo and Müller [2002]
EF in situations with affective or motivational signifi- suggested that hot EF is different from cool EF, but they
cance [Meuwissen & Zelazo, 2014], such as managing coordinate with each other by task demands. For exam-
emotions and controlling impulses in a gambling task, or ple, in the hot EF task, children with ASD need to activate
ending a pleasant conversation and adjusting one’s their cool EF for problem solving and employ their hot
mindset to attend the next class upon hearing a class bell EF for inhibiting emotional impulses. Therefore, they
ring. Compared with TD children, children with ASD may fail in the hot EF task because of their poor cool
have atypical cool and hot EF [Brunsdon et al., 2015; EF. Moreover, the development of hot EF lags behind the
Devine & Hughes, 2014; Kouklari, Thompson, Monks, & development of cool EF. For example, the hot EF of
Tsermentseli, 2017; Kouklari, Tsermentseli, & Monks, school-aged children shows less maturity than their cool

2 Yu et al./Cool EF and verbal comprehension mediate hot EF–ToM link INSAR

EF [Prencipe et al., 2011]. Hence, cool EF could mediate ASD. In addition, the roles of cool EF and verbal compre-
and cooperate with hot EF in tasks involving emotion hension have not been previously explored together to
and motivation during the school-age period. address hot EF–ToM relations. A recent behavioral study
Second, verbal comprehension may be involved in discovered that early hot EF predicted later ToM in chil-
the relations between cool EF and ToM. The relations dren with ASD and average intellectual abilities [Kouklari
between cool EF and ToM have been greatly investi- et al., 2018]. However, the measurements of multifaceted
gated. In Russell’s theory [1997], cool EF is a prerequi- ToM were restricted to emotion recognition tests and
site for ToM, which has also been supported by false belief tasks, and the mechanism of hot EF–ToM
developmental studies [Devine & Hughes, 2014]. The remains unknown in children with ASD. Cool EF and ver-
flexible perspective changing in ToM may require the bal comprehension need to be considered to clarify the
cognitive flexibility of cool EF. Moreover, the links underlying connections between hot EF and ToM. There-
between the development of verbal comprehension fore, the purpose of this study was to examine the corre-
and ToM have been found in both children with TD lations between hot EF, cool EF, verbal comprehension,
and ASD [Happé, 1994b; Ronald, Viding, Happé, & and ToM in children with ASD and average intellectual
Plomin, 2006; Ziatas, Durkin, & Pratt, 1998]. Jacques abilities. We adopted a ToM battery that covers a wide
and Zelazo have proposed that cognitive flexibility is ToM developmental spectrum to address the potential
the indirect connection between verbal ability and mediating effects of cool EF and verbal comprehension
ToM [Jacques & Zelazo, 2005]. Verbal comprehension on the relations of ToM with hot EF. Specifically, we
involves decoding processes for multiple features applied mediation analysis to examine: (a) whether hot
(e.g., word meanings and sounds), which may allow EF is related to ToM and (b) whether cool EF and verbal
children to practice flexible thinking. Greater verbal comprehension mediate the correlation of ToM with hot
ability is related to better flexible thinking, and such EF. We hypothesized that first, hot EF is related to ToM,
flexibility may contribute to perspective taking in ToM. and second, the relations between hot EF and ToM, can
Empirical studies also support that cool EF is related to be mediated by cool EF and verbal comprehension.
verbal comprehension [Ozonoff, Pennington, & Rogers,
1991; Sesma, Mahone, Levine, Eason, & Cutting, 2009]
and ToM [Devine & Hughes, 2014; Kouklari et al., 2018;
Methods
Marcovitch et al., 2015] in both children with TD and Participants
those with ASD. Therefore, these studies highlight the
important role of verbal comprehension in the relation- A total of 97 children with ASD aged from 6 to 12 years
ship between cool EF and ToM in children with ASD. old were recruited from hospitals, clinics, and develop-
Third, although so far no direct links between verbal mental centers in Taiwan from January 2015 to June
comprehension and hot EF have been clearly identified, 2018. The mean age of the 97 children with ASD was
the relations between hot EF and ToM have been shown 8.5 years. Most of the children were boys (89.7%), and
in previous literature. Zelazo, Qu, and Müller [2005] pro- most of the parents were highly educated (64.9–69.1%
posed that motivational or emotional processes need to attended college). The diagnosis of ASD was made by
be evoked to understand the mental states of others. qualified psychiatrists according to the criteria of three
Kouklari et al. [2018] corroborated that early hot EF pre- versions of the Diagnostic and Statistical Manual of Men-
dicts later ToM development in school-aged children tal Disorders (DSM): the fourth edition (DSM-4), text revi-
with ASD. Furthermore, the ventromedial prefrontal cor- sion of the fourth edition (DSM-4-TR), and fifth edition
tex (vmPFC), which is involved in hot EF activities, is also (DSM-5). Children were excluded if they had:
linked to the integration of affective information in ToM (a) neurological dysfunction (e.g., seizures and cerebral
[Sebastian et al., 2011]. These studies supported the palsy); (b) chromosomal abnormality; (c) uncorrectable
underlying linkage between hot EF and ToM. To sum up, visual or hearing impairments; (d) a score < 60 on the
cool EF and verbal comprehension play an important role Social Responsiveness Scale-second edition (SRS-2)
in connecting hot EF and ToM. The links between verbal − school-aged form [Constantino & Gruber, 2012]; (e) a
comprehension and hot EF may be established through score of <70 on the Verbal Comprehension Index (VCI)
their relations to cool EF. Along with cool EF deficits, the of the Wechsler Intelligence Scale for Children-fourth
verbal comprehension of children with ASD may mediate edition-Chinese version (WISC-4); and (f) inability to fol-
the relations between hot EF and ToM deficits. low directions and complete all procedures. The study
protocols were approved and monitored by the Institu-
The Purposes of the Present Study tional Review Boards of National Cheng Kung University
Hospital and Kaohsiung Municipal Kai-Syuan Psychiatric
To date, only a handful of studies have discussed the Hospital. Informed consent was obtained from the chil-
associations between hot EF and ToM in children with dren’s main caregivers and children aged 7 or above.

INSAR Yu et al./Cool EF and verbal comprehension mediate hot EF–ToM link 3

Measures trials and seven switch trials in a pseudo-random order.
The accuracy and reaction time (RT) are recorded in every
Theory of mind. The ToM Task Battery (ToMTB) assesses
trial in the single and mixed block. Higher accuracy and
the understanding of ToM of children aged 2 to 12 years
shorter RT imply better cool EF. The accuracy and RT in
[Hutchins, Prelock, & Bonazinga, 2014]. The ToMTB is
the single and mixed blocks were presented indepen-
appropriate for children with ASD who have either good
dently in this study because accuracy and RT, as well as
or poor verbal expression because children can respond
single and mixed blocks, have their own respective theo-
either by answering verbally or by pointing to the picture
retical concepts and cannot be integrated into one vari-
that shows the correct answer. The ToMTB comprises
able [Prinzmetal, McCool, & Park, 2005; Santee &
15 test questions within nine tasks, which are presented
Egeth, 1982]. We applied a commonly used procedure to
as short vignettes in ascending difficulties of ToM. The
deal with the inadequate RT responses, including wrong
15 test questions assess children’s ToM understanding,
responses and responses with RT < 200 ms as well as >
including identifying emotions associated with facial
mean RT + 2.5 SD in this study [Diamond &
expressions, understanding the visual perspective of
Kirkham, 2005; Dichter et al., 2010]. Children with ASD
others, inferring desire-based emotion, perception-based
have shown deficits in the DCCS task, exhibiting signifi-
belief, perception-based action, and first- and second-
cantly slower and less accurate performance than chil-
order false beliefs. In addition to the test questions, mem-
dren with TD [Dichter et al., 2010].
ory control and justification questions are applied before
and after the test questions. The 11 memory control
Hot executive functions. The Children’s Gambling
questions are designed to confirm comprehension and to
Task (CGT) assesses affective decision-making in hot EF
prevent guessing to answer the test questions. The 15 jus-
[Kerr & Zelazo, 2004]. In the CGT, a child is presented
tification questions are asked only if the child correctly
with two decks of cards (50 advantageous cards and
answers the test questions to discern the quality and
50 disadvantageous cards) for 50 trials of card selection in
nature of the child’s reasoning behind the given
five blocks (ten trials per block). In each trial, the child
response. Each test question is scored 1 or 0, respectively,
selects one card from either of the decks. Each card is
for correct and incorrect answers. The child receives a
divided into two halves, a white top and a black bottom,
score on a test question only if he or she passes the
with black happy and white sad faces, respectively. The
corresponding memory control questions. The ToMTB
number of black happy faces refers to the number of
has shown good reliability and validity in children with
rewards (candies) that the participant gains and appears
ASD [Hutchins et al., 2014; Hutchins, Prelock, &
in the white top, and the number of white sad faces refers
Chace, 2008]. Children with ASD have been found to
to the number of rewards that the participant loses and
have lower ToMTB scores than children with TD [Hutch-
appears in the black bottom. The advantageous cards
ins et al., 2016].
always provide a gain of one reward (i.e., they show one
happy face) together with zero or one loss (for an average
Cool executive functions. The computerized Dimen- of five candies gained per block of ten cards). The disad-
sional Change Card Sort (DCCS) task [Diamond & vantageous cards always provide a gain of two rewards
Kirkham, 2005; Dichter et al., 2010] is a measure of multi- (i.e., they show two happy faces) together with losses of
ple cool EF components, including both flexibility and 0, 4, 5, or 6 candies (for an average of five candies lost per
inhibition [Waxer & Morton, 2011]. Every trial starts block of ten cards). At the beginning of the task, the child
with a sorting criterion (color or shape) and a pair of has 10 candies in a plastic box. As the child gains or loses
response icons (a red boat and a blue rabbit) at the bot- rewards, candies are added or removed by the examiner.
tom of the screen. A target picture (a red rabbit or a blue The CGT score is calculated by subtracting the number of
boat) then presents at the center of the screen. When the disadvantageous choices from the number of advanta-
target is a red rabbit and the sorting criterion is color, the geous choices [Kerr & Zelazo, 2004]. Positive CGT score
correct response is to press the red boat key (identical indicates that the children engaged in relatively advanta-
color) and the wrong response is to press the blue rabbit geous affective decision-making, whereas negative CGT
(identical shape). score indicates that the children engaged in relatively dis-
The DCCS comprises one practice and seven test advantageous affective decision-making. The CGT has
blocks. The practice block presents the sorting criteria in been used in both children with TD and those with ASD
the sequence of eight color and seven shape trials with [Faja, Murias, Beauchaine, & Dawson, 2013].
the feedback of “correct” or “incorrect” for each response.
The test blocks are composed of six single blocks (blocks Verbal comprehension ability. The children’s verbal
1, 2, 3, 5, 6, and 7), each having a single sorting criterion comprehension ability was measured with the VCI of the
of color or shape and ten trials, and one mixed block WISC-IV Chinese version [Chen & Chen, 2007]. The
(block 4), having two sorting criteria with 13 non-switch WISC-4 is an intelligence test for children aged from 6 to

4 Yu et al./Cool EF and verbal comprehension mediate hot EF–ToM link INSAR

16 years 11 months. The VCI of the WISC-IV-Chinese is a effect of CGT score on ToMTB total score with the two
norm-referenced standardized score and comprises three mediators involved. The two parallel indirect effects
core subtests of Vocabulary, Similarities, and Comprehen- were, respectively, the products of the α1 (CGT score
sion. The WISC-4-Chinese has good reliability and good on DCCS variable) and β1 (DCCS variables on ToMTB
convergent and construct validity [Chen, Keith, Chen, & total score) effects and the products of the α2 (CGT
Chang, 2009]. score on VCI) and β2 (VCI on ToMTB total score)
effects. The serial indirect effect was the product of the
Severity of the symptoms of autism. The Social α1, γ1 (DCCS variable on VCI), and β2 effects. The total
Responsiveness Scale-second edition (SRS-2) − school- effect was calculated by summing the direct and all
aged form is a parent-report measure of the autistic symp- indirect effects.
toms of 4- to 18-year olds [Constantino & Gruber, 2012]. A total of four mediation models were examined in
The SRS-2 includes 65 items, which are categorized into this study. In these four models, the mediators were,
five treatment clusters: social awareness, social cognition, respectively, the four DCCS variables together with the
social communication, social motivation, and restricted VCI, the predictor was the CGT score, and the depen-
interests and repetitive behavior. Each item is rated from dent variable was the ToMTB total score. Only the
1 (not true) to 4 (almost always true). The total raw scores models in which DCCS variables were significantly
can be converted into T-scores referenced with the age related to ToMTB total scores were chosen for further
norms. T-scores of <60, 60–65, 66–75, and > 76, respec- mediation analysis. The bootstrapping procedure with
tively, indicate children within the normal limits and 10,000 repetitions was applied to verify the mediator
with mild, moderate, and severe autistic symptoms. The effect in all statistical models. This method has been spe-
psychometric properties of the SRS-2 are well established, cifically designed to obtain reliable and valid conclu-
including good reliability and convergent validity sions in studies where the sample sizes are insufficient
[Constantino & Gruber, 2012]. [Preacher & Hayes, 2004]. A 95% confidence interval
was applied to perform the effect estimations. If the
indirect effect of the mediators was significantly differ-
Experiment Procedures
ent from zero, the indirect effect was considered signifi-
The children were assessed with the WISC-4 first, and cant. Statistical significance was set as a P-value of 0.05
then with the ToMTB, DCCS, and CGT by a trained for the other analyzes. The statistical analyzes were per-
researcher. Their caregivers were requested to fill out the formed in the Statistical Package for the Social Sciences
basic information sheet and the school-aged form of the (SPSS, version 22; SPSS Inc., Chicago, IL, USA), and the
SRS-2. All the assessments were completed within 1 hr. PROCESS v3.1 package [Hayes, 2017] was applied for the
mediation analysis.
Statistical Analysis

Descriptive analyzes were computed for demographic

Results
and experimental data. Paired t-tests were applied to test Participant Characteristics and the Performance of Tasks
whether diversity existed in the accuracies and RTs
between single and mixed blocks. Partial correlation coef- Table 1 shows the descriptive statistics of the participant
ficients were applied while controlling for age as a covari- characteristics, autistic symptoms, verbal ability, ToM,
ate to examine the correlations between all measured and cool/hot EF. The mean scores of the SRS-2 and VCI
variables, including the SRS-2 total T-score, VCI, DCCS indicated that the majority of the children had moderate
variables (i.e., accuracies and RTs in both single and to severe autistic symptoms and average verbal compre-
mixed blocks), CGT score, and ToMTB total scores. Medi- hension ability. ToMTB mean scores (mean ± SD:
ation analysis with the effect of age controlled for was 10.2 ± 2.7, range: 4–15) indicated that the children with
applied to examine the mediating effects of the DCCS ASD in our study were in early to advanced ToM develop-
variables and VCI on the relations between CGT score mental stages. Forty-one (34.7%) children with ASD
and ToMTB total score. Total, direct, and indirect effects showed delays in ToM development based on their devel-
were examined to confirm the mediating effects. The opmental stages from the ToMTB score interpretation.
total effect was used to examine the influence of CGT The accuracies of the DCCS were greater than 0.5, indi-
score on ToMTB total score without the mediators in the cating that the children’s cool EF was better than
regression model. In each mediation model, the four guessing. The mixed block was more difficult than the
pathways, one direct and three indirect effects, were single block, for the children with ASD had lower accuracy
examined to inspect the influence of CGT score on [t(96) = 5.51, P < 0.001] and longer RTs [t(96) = −6.91,
ToMTB total score with the two mediators (i.e., a DCCS P < 0.001] in the mixed block. A significant correlation
variable and VCI). The direct effect was calculated as the was found between accuracy and RT in the single block

INSAR Yu et al./Cool EF and verbal comprehension mediate hot EF–ToM link 5

Table 1. Characteristics and Measured Variables in Children with Autism Spectrum Disorder
Variables Mean/frequency SD Range

Age (years) 8.5 1.7 6–12.1

Gender (boys), n (%) 87 (89.7)
Parental education (attended college), n (%)
Father 67 (69.1)
Mother 63 (64.9)
Family income (above average), n (%) 43 (44.3)
SRS-2 79.1 10.4 60–109
VCI 106.0 17.25 73–154
ToMTB total score 10.2 2.7 4–15
Dimensional Change Card Sort Task
Single block
Accuracy (%) 90.1 10.2 35.0–100.0
Reaction time (ms) 1418.3 510.7 640.3–3166.1
Mixed block
Accuracy (%) 84.4 11.1 55.0–100.0
Reaction time (ms) 1670.5 679.9 711.5–5160.5
Children’s Gambling Task 11.1 15.8 −28–50

Note. Values are given as means (SD) or numbers (%); total case numbers were 97 (n = 97); ms: milliseconds; SRS-2: Social Responsiveness Scale-
second edition; ToMTB: Theory of Mind Task Battery; VCI: Verbal Comprehension Index of the Wechsler Preschool and Primary Scale of Intelligence-fourth
edition or the Wechsler Intelligence Scale for Children-fourth edition.

Table 2. Partial Correlations on Variables of Cool and Hot Executive Function and Theory of Mind
1 2 3 4 5 6 7

1 ToMTB total score

2 Children’s Gambling Task 0.20*
3 DCCS single block accuracy (%) 0.23* 0.29**
4 DCCS single block reaction time (ms) −0.22* 0.16 0.54***
5 DCCS mixed block accuracy (%) 0.14 0.03 −0.44*** −0.22*
6 DCCS mixed block reaction time (ms) −0.17 0.07 −0.24* −0.08 0.84***
7 Verbal Comprehension Index 0.52*** 0.10 0.32** 0.34** −0.41*** −0.38***
8 Social Responsiveness Scale, second edition −0.01 −0.04 −0.05 −0.05 −0.11 −0.11 −0.08

Note. Values are given as Pearson’s correlation coefficient; total case numbers were 97 (n = 97); DCCS: computerized Dimensional Change Card Sort;
ToMTB: Theory of Mind Task Battery.
*P < 0.05; **P < 0.01; ***P < 0.001.

(r = −0.44, P < 0.001) but not in the mixed block The Mediating Effects of Cool EF on the Relations between
(r = −0.08, P = 0.467) with age controlled for. The CGT Hot EF and ToM
mean score was positive, indicating that the children
chose more cards from the advantageous deck than from Since only the single task accuracy and RT of the DCCS
the disadvantageous deck. variables were significantly related to ToMTB, two media-
tion models were, respectively, further examined to deter-
mine whether the single accuracy/RT together with VCI
The Correlations of Cool and Hot EF with ToM with Age mediated the relationship between CGT score and
Controlled For ToMTB total score. Figure 1 shows the mediating effects
of DCCS single accuracy and VCI on the relation of CGT
The results of partial correlations showed significant cor- to ToMTB. The direct effect of CGT on ToMTB and the
relations of the accuracy (r = 0.23, P = 0.022) and RT two parallel indirect effects (CGT ! single accuracy !
(r = −0.22, P = 0.031) with the total score of the ToMTB ToMTB and CGT ! VCI ! ToMTB) were not statistically
in the single block of the DCCS task (Table 2). The CGT significant (all 95% CI contained zero). The serial indirect
score was also significantly related to the total score of effect (CGT ! single accuracy ! VCI ! ToMTB) was sta-
the ToMTB while controlling for the effect of age tistically significant (95% CI = [0.002, 0.02], Figure 1).
(r = 0.20, P = 0.049, Table 2). The mediating effects of single RTs and VCI on the

6 Yu et al./Cool EF and verbal comprehension mediate hot EF–ToM link INSAR

Figure 1. The mediating effects of the computerized Dimensional Change Card Sort (DCCS) single accuracy and Verbal Comprehension
Index (VCI) on the relation of the Children’s Gambling Task (CGT) to the Theory of Mind Task Battery (ToMTB). All the effects were tested
with the bootstrapping method based on 10,000 times of resampling. Solid lines indicate significant effects, while dashed lines indicate
insignificant effects. The 95% confidence intervals of all effects are presented in square brackets. If the 95% confidence interval con-
tains zero, the effect is considered insignificant.

relation of CGT to ToMTB did not show any significant The results of mediation analysis supported our
direct or indirect effects (all 95% CI contained zero). hypothesis that cool EF and verbal comprehension medi-
ate the relations between hot EF and ToM, which was
consistent with the evidence of functional connectivity
within the prefrontal cortex. As mentioned earlier, the
Discussion vmPFC is related to hot EF and ToM [Abu-Akel &
Shamay-Tsoory, 2011; Sebastian et al., 2011]. Addition-
Our mediation analysis produced two main results. First, ally, the dorsolateral region (dlPFC) is correlated with
hot EF was significantly correlated with ToM. Second, cool EF [Elliott, 2003], while the ventrolateral prefrontal
cool EF and verbal comprehension ability together medi- cortex (vlPFC) is involved in hot EF (i.e., emotional regu-
ated the correlation between hot EF and ToM. These lation), cool EF and verbal comprehension [Elliott, 2003;
results indicate that cool and hot EF may not relate to Hoffman, Jefferies, & Lambon Ralph, 2010; Wager,
ToM in the same way. The present study supports the Davidson, Hughes, Lindquist, & Ochsner, 2008]. The
relations between hot EF and ToM and highlights the dlPFC has been proposed to monitor and select the repre-
important roles of cool EF and verbal comprehension in sentations in the vlPFC [Elliott, 2003; Wagner, Maril,
linking hot EF and ToM in children with ASD and aver- Bjork, & Schacter, 2001]. Moreover, the vlPFC is able to
age intellectual abilities. recruit information from the vmPFC during the
Our results are consistent with those of previous stud- processing of social cues [Marsh, Blair, Jones, Soliman, &
ies, which have supported the proposition that both cool Blair, 2008]. Therefore, in an anxiety-causing social situa-
and hot EF are related to ToM [Kouklari et al., 2017; tion, the dlPFC (i.e., cool EF) may regulate the vlPFC
Kouklari et al., 2018]. For example, children with ASD (i.e., hot EF, cool EF, and verbal comprehension) to col-
who show cognitive inflexibility may have difficulties in lect processed information from the vmPFC (i.e., hot EF
perspective taking to infer others’ mental states. The per- and ToM) for deciphering the social cues. These
spective taking ability correlates with social competence evidenced prefrontal cortex connections support our
deficits in children with ASD [Dawson & Fernald, 1987]. results and imply the roles of cool EF and verbal compre-
On the other hand, children with ASD who have poor hension in hot EF–ToM relations.
hot EF may show difficulties in emotion regulation and The speed–accuracy trade-off may explain why the
then fail to apply ToM to be aware of others’ motivations mediating effects of cool EF were only found in the single
and emotions in situations involving interpersonal con- block accuracy. Children with better cognitive ability
flict. These failures of ToM may lead to the social interac- may achieve fast response speeds while maintaining high
tion and communication deficits in children with ASD accuracy; otherwise, they may sacrifice speed, and thus
(Baron-Cohen, 1992, 1997; Baron-Cohen et al., 1985). have slower responses, to maintain accuracy, which is
Therefore, in children with ASD, better cool and hot EF the speed–accuracy trade-off [Plamondon & Alimi, 1997].
are related to better use of ToM. Children with ASD can compensate for their inferior cool

INSAR Yu et al./Cool EF and verbal comprehension mediate hot EF–ToM link 7

EF processing by slowing their response speed to achieve necessity of considering the mediating role of cool EF
accuracy comparable to that of TD children, but they are and verbal comprehension on hot EF–ToM relations in
no longer able to do so when task demands increase clinical assessments of and interventions for children
[Evers, Noens, Steyaert, & Wagemans, 2011]. When they with ASD and average intellectual abilities.
need to deal with tasks involving both hot EF and ToM,
cool EF cannot be further employed to achieve fast
responses or meet complex cognitive task demands with Acknowledgments
limited resources. Therefore, the mediating effects were This study was supported by grants from the Ministry of
very likely to be established in accuracy rather than in RT Science and Technology (MOST103-2410-H-006-060,
in the children with ASD and average intellectual abilities MOST104-2410-H-006-065, MOST105-2410-H-006-047-MY2,
in this study. MOST107-2314-B-006-023-MY3, and MOST107-2314-B-
Our study highlights the hot EF–ToM relation and the 002-046-MY3) in Taiwan. The authors acknowledge the
importance of cool EF and verbal comprehension in the generosity of participating families for their important
relations between hot EF and ToM. These findings can contribution to this research. The authors specially thank
improve understanding of the heterogeneity of cognitive the medical teams of the Department of Child and
impairments and the way EF and verbal comprehension Adolescent Psychiatry in Kaohsiung Municipal Kai-Syuan
deficits interact, which may also contribute to under- Psychiatric Hospital and the Department of Psychiatry in
standing of the social difficulties of children with ASD. In Chi Mei Medical Center for their assistance in partici-
clinical practice, assessing hot EF, cool EF, and verbal pants recruitment.
comprehension impairments could inform clinicians for
better reasoning about cognitive correlates to improve
ToM, which may further facilitate social interaction in Conflict of Interest
children with ASD. Clinicians may enhance ToM by
The authors declared no conflicts of interest to this work.
intervening in cool EF and verbal comprehension in chil-
All the authors do not have any commercial or associa-
dren with ASD who have hot EF deficit or by improving
tive interest that represents a conflict of interest in con-
hot EF in those who have poor cool EF and verbal com-
nection with the work submitted.
prehension. The results of this study suggest alternative
potential pathways to improve ToM in children
with ASD.
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