This study aims to investigate how internalizing and externalizing symptoms, along with executive functions, predict empathy. Our results revealed that working memory and externalizing symptoms predicted cognitive empathy, while only externalizing symptoms predicted affective empathy. These findings are typically consistent with the hypotheses of this study.
Empathy and Internalizing Symptoms
In our hypothesis, we predicted that there would be significant positive correlations between internalizing symptoms and affective empathy but no significant correlations with cognitive empathy. Our study revealed no significant relationships between internalizing symptoms and cognitive and affective empathy. Our study revealed no relationship between self-reported and task-based empathy scale scores. Murphy and Lilienfeld [76] and Bray et al. [14] found that self-reported empathy and task-based empathy measures are not related. The absence of a connection between self-reported empathy and performance on empathy tasks in our sample might suggest that this age group may still be developing the meta-cognitive skills required to accurately assess their own cognitive empathy abilities. The lack of associations between self-reported and task-measured empathy may be due to differences in measurement approaches: self-reports reflect personal perceptions and biases, while task measures capture objective, situational responses.
In a recent study involving 174 children between the ages of 4 and 8 years who were referred to the clinic due to internalizing and externalizing symptoms, it was found that anxiety symptoms negatively predicted affective empathy. At the same time, there were no significant relationships with cognitive empathy [42]. The authors stated that anxious children may be less capable of adequately sharing and responding appropriately in emotional situations. Morrison et al. [76] also reported that adults with social anxiety disorder had more difficulty indirectly sharing the positive emotions of others than healthy controls.
However, a study involving 127 children aged 9–10 years revealed that affective sharing and empathic distress components of affective empathy had significant relationships with internalizing symptoms, particularly with social anxiety disorder symptoms [14]. A study of 1223 children found that low cognitive empathy may increase the risk of depression, while moderate to high cognitive empathy was not associated with depression [44]. Another study of 170 children and adolescents aged 9–15 found no significant relationships between affective empathy and depression symptoms [47].
Given the cross-sectional design of our study, it is not possible to determine whether affective empathy and its subdimensions are risk factors for developing internalizing symptoms in children, or if internalizing symptoms negatively impact empathic processes. No significant relationships were found in our study. There are contradictory results in the literature. In our study, empathy was assessed by task-based measurement as a situational/contextual dimension and by scale as a continuous dimension. However, we may not have identified affective empathy subdimensions related to internalizing symptoms such as empathic distress. It is essential to examine affective empathy subdimensions in detail in future studies.
Tone and Tully [46] suggest that high levels of empathic distress might increase the risk of internalizing disorders through various intrapersonal or interpersonal factors. Similarly, Zahn-Waxler and Van Hulle [78] noted that high affective empathy alone is not a risk for psychopathology but may become a risk factor for anxiety and depression when combined with adverse life events. Internalizing symptoms can also impair empathic skills. Follow-up studies incorporating factors like stressful life events will help clarify the temporal relationships between empathy and internalizing symptoms.
Empathy and Externalizing Symptoms
In our hypothesis, we predicted that externalizing symptoms would be negatively related to affective and cognitive empathy. Our study revealed significant negative correlations between externalizing symptoms and both cognitive and affective empathy.
In a recent study, 92 children with externalizing symptoms such as conduct disorder with an average age of 9 years were revealed to have deficits in cognitive and affective empathy skills compared to the control group [60]. Affective and cognitive empathy skills are thought to prevent the development of externalizing symptoms by increasing positive social behaviors [57]. Another study conducted with 507 adolescents aged 12–17 years revealed that high levels of affective and cognitive empathy were negatively associated with externalizing symptoms [45].
Childhood psychiatric disorders with externalizing symptoms, such as attention deficit hyperactivity disorder [38, 61] and disruptive behavior disorders [79, 80] are associated with cognitive and affective empathy deficits. The observation of empathy difficulties in children with conduct disorder symptoms and psychopathic features who do not meet psychiatric diagnostic criteria [81] has led to the evaluation of empathy difficulties as a risk factor in the social development of children before the development of psychiatric disorders.
In children with externalizing symptoms, difficulties in understanding and responding to the emotional states of others are associated with interpersonal and social problems [82]. These interpersonal and social problems negatively affect children's affective and cognitive empathy skills. Cox et al. [83] argued that the ratio of affective empathy to cognitive empathy is associated with externalizing symptoms such as trait aggression and impulsivity.
These deficits in empathy skills may be partly explained by the impulsivity typically observed in children with externalizing symptoms such as ADHD. Frontostriatal brain network dysfunction affects empathic processing and executive dysfunctions [62]. The behavioral inhibition deficits observed as core symptoms in children with ADHD may impair impulsivity as well as social cognition skills. However, the extent to which children's empathy is affected is still unclear [63].
In our study, externalizing symptoms significantly predicted affective and cognitive empathy difficulties. In our sample of treatment-naïve young people in whom externalizing symptoms are commonly observed, it was not possible to examine the temporal relationships of empathy deficits with psychiatric disorder diagnoses and comorbidities in detail. It will be helpful to monitor the related relationships in future follow-up studies.
Empathy and Executive Functions
Our hypothesis predicted that working memory would be positively related to cognitive empathy but not significantly related to affective empathy. We predicted that inhibition would be positively related to cognitive and affective empathy. As a result of our study, only cognitive empathy and working memory were positively correlated. Although the other relationships were also positive, they were not statistically significant. As predicted in our hypothesis, executive functions are more closely related to cognitive empathy than affective empathy.
Studies with community and clinical samples showed that executive functions can regulate empathic attitudes; in other words, people with higher executive functions will regulate their emotions better and perceive less distress during empathic processes [26, 84]. Executive functions serve as a key to regulating our empathy toward the emotions of others. High executive functioning skills are a prerequisite for high levels of empathy [13, 31].
A recent meta-analysis study stated that empathy is strongly associated with executive functions with cognitive empathy showing a closer relationship to executive functions than affective empathy [36]. This meta-analysis is particularly important as it synthesizes findings from multiple studies, presenting a broad view of these relationships and emphasizing the relative strength of the connection between cognitive empathy and executive functions compared to affective empathy.
It is stated that there may be differences in the relationship of executive functions with empathy according to diagnoses and comorbidities, and heterogeneous results may be observed about this [85]. Our study observed non-significant positive relationships between inhibition and cognitive and affective empathy. The lack of significant relationships in our sample with psychiatric symptoms from different diagnostic clusters may be the reason why we obtained different results from studies focusing on psychiatric disorders such as ADHD. Examining the related relationships between different psychiatric disorders and comorbidities will help clarify our results.
Limitations
Some limitations should be noted in our study. We based our evaluation of executive functions a two-factor model (working memory and inhibition) for adolescents [27], cognitive flexibility also impacts the relationship between executive functions and empathy [36, 37]. Additionally, we did not account for children's IQ scores, despite evidence suggesting their relevance to cognitive and affective empathy [42, 60]. Future studies should consider IQ scores, even in community samples. It is also important to note that parents and children may have differing perspectives on symptoms or behaviors. Parents might observe more external behaviors, while children might report internal experiences more accurately. This can lead to discrepancies in ratings and future research should consider addressing this limitation. Another limitation of our study is that children's psychiatric symptoms were evaluated only with the SDQ, and no additional assessment was performed. Although we conducted our study in a community sample and did not focus on any psychiatric or neurodevelopmental diagnosis, studies with large samples are needed to evaluate the effects of different diagnoses on cognitive and affective empathy in internalizing and externalizing symptoms. Although there are a limited number of studies evaluating the relationships between internalizing disorders and empathy [14], externalizing disorders, executive functions, and empathy [38] in the age group similar to the sample in our study, studies including different diagnoses in the relevant age group are needed. Furthermore, empathy was selected as the outcome variable in the regression analysis because our primary focus was to examine how various factors, such as executive functions and internalizing symptoms, influence empathic abilities. However, we acknowledge the importance of exploring the reverse direction, where empathy could potentially predict psychopathology. Future research should include this perspective to provide a better understanding of the bidirectional relationships between empathy and psychopathological outcomes.
Furthermore, the subcomponents of affective empathy should have been evaluated. Although cognitive and affective empathy was tested with the task-based method, the evaluation of components of affective empathy, such as empathic distress [46, 48], which seem to be more closely related to psychiatric disorders, in the relevant age group will contribute to our study. The limited number of scales and task-based methods evaluating the sub-dimensions of affective empathy in this age group led us not to evaluate the related relationships in detail. In addition, as in previous studies [14, 76], a significant relationship between the scale we applied in our study and task-based empathy measurements was not observed. The use of additional methods that will provide a detailed evaluation of empathy in this age group will contribute to evaluating our results.
A cross-sectional study is another limitation of our study. Different results can be observed in studies involving empathy, executive functions, and different psychiatric diagnoses [14, 38, 45, 61, 82, 86]. Follow-up studies, including mutual interactions in related relationships, will contribute to the elucidation of our results. Although our study was conducted with a relatively large population sample with psychiatric symptoms, follow-up studies with larger samples will contribute to revealing the temporality in the relationship between internalizing and externalizing symptoms and empathy.
Finally, the potential ceiling effect might have influenced our results (e.g., cognitive scores) by limiting the variability in scores, particularly among participants who performed at the high end of the scale. This restriction could have obscured differences between individuals and made it more challenging to detect significant relationships or effects. Consequently, the observed associations or lack thereof may not fully reflect the true range of variability in the population, potentially underestimating the impact of certain variables or interventions.