Relationships between Empathy, Executive Functions, and Internalizing and Externalizing Symptoms in Early Adolescents

Relationships between Empathy, Executive Functions, and Internalizing and Externalizing Symptoms in Early Adolescents | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Relationships between Empathy, Executive Functions, and Internalizing and Externalizing Symptoms in Early Adolescents Onat Yetim, Resul Çakır, Lut Tamam This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4801384/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Nov, 2024 Read the published version in BMC Psychiatry → Version 1 posted 4 You are reading this latest preprint version Abstract Background Previous studies have shown associations between internalizing and externalizing symptoms, executive functions, and empathy. However, the mechanisms that affect this relationship remain unclear. This study employed regression analysis to explore the predictive effect of internalizing and externalizing symptoms and executive functions on empathy. Method Our study consisted of three consecutive stages. In the first stage, we assessed 2150 adolescents’ parents of 2150 adolescents aged 10–12 years using the Strengths and Difficulties Questionnaire to determine which participants should be included in the subsequent stages. In the second stage, we conducted a pilot study with 50 participants to assess the validity of the assessment system and the six film scenes to be used in the following stage. Finally, in the third stage, we obtained the participants' state empathy, trait empathy, and executive functioning. Results The regression analysis showed that working memory performance ( β = 0.261) and externalizing symptoms ( β = -0.157) predicted cognitive empathy, but only externalizing symptoms predicted affective empathy ( β = -0.193). Conclusion This study highlights the effect of externalization on both cognitive and affective empathy and the effect of working memory on cognitive empathy. These findings may serve to inform psychological interventions to improve empathic abilities in early adolescence. Empathy executive functioning internalization externalization Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Adolescence, characterized by the increased significance of social interaction, is a critical age for both empathy and executive functions, and neural and behavioral alterations occur during this period [ 1 , 2 , 3 ]. Empathy skills can be crucial at these ages [ 1 , 4 ], and are affected by and individual’s cognitive abilities [ 5 ]. One reason for this effect could be that the transition from childhood to adulthood is accompanied by major changes in the brain, specifically significant neural changes in the prefrontal cortex that underlie executive functions and empathy [ 6 ]. During early adolescence, individuals often encounter high levels of stress stemming from acute daily stressors, family dysfunction, or economic problems [ 7 , 8 ]. A large body of evidence indicated that many psychosocial factors (e.g., adverse childhood experiences and trajectories and trauma) were found to be associated with both internalizing symptoms, such as anxiety and depression [ 9 , 10 ], and externalizing symptoms, such as aggression and conduct problems [ 7 , 11 , 12 ]. In summary, considering the relationships between executive functions and empathy [ 13 ] and between symptoms of internalization [ 14 ] and symptoms of externalization [ 15 ], executive functions and these psychopathological symptoms may predict an individual's empathic tendency. Empathy Empathy, as an umbrella term, is defined as the ability to understand, experience, and respond to the emotional state of another human being [ 16 , 17 ]. Most researchers consider empathy a multifaceted construct, primarily encompassing cognitive empathy, defined as the ability to understand and consider the emotional states of others, and affective empathy, defined as the ability to share and experience the emotions of another person [ 14 , 18 , 19 ]. The essential components of affective empathy emerge in children very early [ 20 ]. Concerning affective empathy, cognitive empathy skills also develop at 4–5 years of age. The development of cognitive empathy skills continues in early and middle childhood in conjunction with the development of frontotemporal and parietal regions [ 21 ]. In middle and early adolescence, cognitive empathy skills increase with age in parallel with the maturation of executive function skills [ 22 , 23 ]. Linking Empathy to Executive Functioning Executive functioning (EF) is an umbrella term for higher cognitive functions such as working memory, inhibition, and cognitive flexibility [ 16 , 24 ]. Studies conducted on adults often focus on these three dimensions of executive functions. However, during early and middle childhood, executive functions show linear development and are evaluated as one-dimensional [ 25 , 26 , 27 ]. In adolescence, the development of the prefrontal cortex leads to the maturation of executive functions [ 28 , 29 ]. Studies on executive functions in adolescence show differences. While some studies support a highly interrelated three-factor structure in children aged 8–13 years [ 30 ], other studies emphasize that the two-factor (inhibition and working memory) executive function model is valid in children aged 5–13 years, while the three-factor model (inhibition, set switching, and working memory) emerges after the age of 15 [ 27 ]. Executive functions are a fundamental component of cognitive empathy [ 13 , 31 ]. Studies show that various subcomponents of executive functions, such as working memory and cognitive flexibility, contribute differently to empathy, influencing how we interpret and predict others' behaviors 32]. While inhibition helps to suppress our automatic responses, working memory helps to preserve emotional processing. When we empathize with others, inhibition helps us to prevent emotional contamination and regulate our emotions as we manage our concerns for others. As cognitive abilities, EF can influence various aspects of social cognition, including both cognitive and affective empathy [ 32 ]. Empathy is one of the motivating forces behind our social behavior [ 16 ]. Across both evolution and development, early arising empathic capacities such as experience sharing are later layered with the ability to draw specific attributions about what others feel, want, and need, even when the targets’ experience diverges from the observers’ own [ 33 ]. These advances in social cognition allow children to overcome obstacles and socially modulate their emotions [ 34 ]. Two interrelated processes, bottom-up (involves the sensory-driven, automatic response to external stimuli) and top-down (involves higher-level cognitive functions, such as reasoning, expectations, and prior knowledge) information processing, are thought to underpin empathy [ 13 , 31 ]. Executive functions may function to regulate our empathic approach toward others [ 13 , 35 ]. A recent meta-analysis revealed that empathy is strongly associated with executive functions, emphasizing that cognitive empathy is more closely related to executive functions than affective empathy [ 36 ]. This study revealed strong relationships between cognitive empathy and inhibition, working memory, and cognitive flexibility, whereas affective empathy was only associated with inhibition [see also, 37]. However, studies also show that executive functions are more strongly associated with affective empathy than with cognitive empathy [ 38 ]. The inclusion of varying age groups and psychopathologies in studies on children and adolescents may affect the results. Our study will assess relevant relationships in a community sample of 10-12- year-olds with psychiatric symptoms but without clinical diagnoses or psychotropic medication. Linking Empathy to Internalizing Symptoms The results of previous studies on empathy and internalizing symptoms suggest that high levels of affective empathy can include negative aspects such as emotional contagion, where a person’s emotions are strongly influenced by others, increasing susceptibility to others' distress and potentially heightening internalizing symptoms [ 39 , 40 ]. However, children with internalizing symptoms often experience intense adverse effects, leading to inflexible processing of social and emotional information, which can worsen interpersonal difficulties, especially in those with anxiety disorders [ 41 , 42 ]. Impaired social functioning is also common in individuals with clinical and subthreshold depression symptoms [ 43 , 44 ]. High levels of affective empathy are thought to lead to internalizing disorders such as depression and anxiety in children and adolescents [ 45 , 46 ]. However, findings from studies of the relationship between empathy and internalizing symptoms in children and adolescents appear to be inconsistent. For example, in a study of 170 children and adolescents aged 9–15 years, no significant relationship was found between levels of affective empathy and symptoms of depression [ 47 ]. In another study, high levels of empathic distress and empathic concern, which are components of affective empathy, were found to be significantly associated with internalizing symptoms such as depression and anxiety disorders in adolescents aged 13–16 [ 48 ]. Low cognitive empathy is significantly linked to anxiety symptoms in children aged 6–11 years [ 49 ]. A recent study of 127 children aged 9–10 years found that affective empathy, emotional sharing, and empathic distress were positively associated with internalizing symptoms, especially social anxiety disorder, but cognitive empathy showed no significant relationship with internalizing symptoms [ 14 ]. Another study of 1,223 adolescents (average age 10.5 years) reported that low cognitive empathy may increase the risk of depression, though moderate to high cognitive empathy was not significantly associated with depression symptoms [ 44 ]. The interactions between empathy skills and internalizing symptoms are closely related to emotion regulation skills [ 50 ]. Since deficits in executive functioning can lead to challenges in emotion regulation [ 51 , 52 ], difficulties in the sociocognitive process—such as cognitive distortions, attentional biases—found in internalizing disorders may also negatively affect children's empathy skills [ 42 ]. However, in light of recent studies, we predicted that internalizing symptoms would be positively associated with affective empathy but not with cognitive empathy in our study. Linking Empathy to Externalizing Symptoms Empathy is related to various contextual factors, early childhood experiences, and social behaviors. Therefore, children with psychopathologies often exhibit deficits in empathy, as these factors can influence the development and expression of empathetic abilities [ 53 , 54 ]. Studies conducted with children and adolescents highlight that there are significant associations between externalizing symptoms such as conduct disorder, oppositional defiant disorder, aggressive behavior and callous, unemotional traits and low levels of empathy [ 15 , 55 , 56 ]. Affective and cognitive empathy skills may prevent the development of externalizing symptoms by increasing positive social behaviors [ 57 ]. A study of 507 adolescents aged 12–17 that high affective and cognitive empathy levels were negatively associated with externalizing symptoms [ 45 ]. Reduced or absent empathy forms the basis of conduct disorder, characterized by disruptive and antisocial behavior [ 58 , 59 ]. A recent study revealed that 92 children with externalizing symptoms such as conduct disorder, with an average age of 9 years, had deficits in cognitive and affective empathy skills compared to the control group [ 60 ]. However, deficits in both affective and cognitive components of empathy are also observed in children diagnosed with combined attention deficit hyperactivity disorder (ADHD), which is often associated with disruptive behavior disorders [ 61 ]. These deficits in empathy may be partly explained by the impulsivity typically observed in children with externalizing symptoms such as ADHD. Dysfunction in frontostriatal brain networks appears to impact both empathic processing and executive dysfunction [ 62 ]. It has been suggested that the behavioral inhibition deficits, as a core symptom in children with ADHD, may impair both impulsivity and cognitive skills. However, the extent to which children's empathic abilities are affected remains unresolved [ 63 ]. Given these data, our study will also consider executive function deficits when assessing the relationships between externalizing symptoms and affective and cognitive empathy. The Current Study Despite the available research on the associations between empathy, executive functioning, and psychiatric symptoms in children and adolescents that have been explored in the literature, the mechanism driving these relationships is still not well understood. Based on the literature, we hypothesized that (a) executive functioning would be more strongly related to cognitive empathy than to affective empathy, (b) internalizing symptoms would be positively correlated with affective empathy but (c) not with cognitive empathy, and (d) externalizing symptoms would negatively related to both affective and cognitive empathy. General Procedures An exploratory quantitative research design guided the cross-sectional sampling method to recruit adolescents from diverse schools in Mersin, Turkey. Using a convenience sampling approach, potential participants at public schools in Mersin, were invited to participate in the research. Written informed consent was obtained from a parent or legal guardian, and participants also provided written assent. This study comprised three stages. In the first stage, we recruited 2,398 early adolescents and their parents. Parents evaluated their children using the Strengths and Difficulties Questionnaire (SDQ) parent form. After excluding 161 participants with more than 25% missing data and 87 based on Mahalanobis distance, we analyzed data from 2,150 participants. In the second stage, we selected participants with an SDQ total score of 10 or less. We conducted a pilot study to validate the film clips and the Cardiff empathy coding system for the next phase, using these participants as a comparison group. This phase included 50 participants, all of whom completed the measurements. In the third stage, we included participants with an SDQ total score above 10. We assessed their empathic tendencies using the validated film clips and the Empathic Tendency Scale for Children and Adolescents. Participants also completed the digit span and Stroop tests. A schematic diagram of the study is shown in Fig. 1. The present study complied with the regulations of the University Ethics Committee, and data collection was carried out between September 2023 and January 2024. The study was conducted in agreement with the Declaration of Helsinki. Stage 1 In the first stage, we conducted a screening study with the Strengths and Difficulties Questionnaire (SDQ) to determine which participants should be included in the later stages of our study. To achieve this, we collected data from the parents of children attending schools in Mersin, Turkey, which provided formal education and volunteered to participate in the study. Method Participants The sample of this stage consists of 2150 parents with children aged 10–12 years (mean = 11.14, SD = 0.70) who are enrolled in formal education. Procedures Written informed consent was obtained, followed by written permission from the participants’ parents. Parents who completed the consent form could read and write in their native language and volunteered to participate in this stage. They were included in the data collection process. The data were collected from 2398 parents, but after checking for invalid data, the number of participants was reduced to 2150. The Strengths and Difficulties Questionnaire (SDQ) was used for data collection. In this study, children with a total SDQ score above ten were invited to the third stage of our study, and children with a total SDQ score of 10 and below were invited to the second stage of our study. Measurements Indicators of Internalization and Externalization In this stage, the Strengths and Difficulties Questionnaire (SDQ) parent form was used to determine the participants’ level of psychological problems. The Strengths and Difficulties Inventory was developed by Goodman [ 65 ] to assess the emotional and behavioral problems of children aged 4–16 years. The scale comprises 25 items across five subdimensions: attention deficit and hyperactivity disorder, behavioral problems, emotional problems, peer problems, and social behaviors. Each subdimension yields a separate score, or a total difficulty score can be calculated. For this study, the strengths and difficulties inventory was evaluated under two subdimensions (internalization and externalization), following Goodman and Goodman's [ 66 ] recommendation for community samples. Emotional symptoms and peer relationships were considered internalizing dimensions, with higher scores indicating greater internalizing symptoms. Behavioral problems and hyperactivity were considered externalizing dimensions, with higher scores indicating greater externalizing symptoms. The scale was standardized for Turkish by Güvenir et al. [ 67 ]. In their study, Cronbach's alpha coefficients were .73, .65, .80, .37, and .73 for emotional, behavioral, attention deficit, peer problems, and social behavior subdimensions, respectively, with an overall score of .84. In the present study, the Cronbach's alpha coefficients were .69 for emotional symptoms, .70 for peer relations, .52 for behavioral problems, .58 for hyperactivity, .86 for prosocial behavior, .65 for internalization, .73 for externalization, and .82 for the total scale score. Statistical Approach Before the analysis, normality assumptions were tested using skewness and kurtosis scores. All variables’ skewness and kurtosis scores are within acceptable limits [ 64 ]. All the statistical analyses were performed using JASP 0.18.1 software. At this stage, we used only descriptive and inferential statistical analysis methods to determine the children to be included in the different stages of our study. Thus, we obtained the total SDQ score of the children to be invited to the following stages and the internalization and externalization scores to be used in the following stages. Results Descriptive and inferential statistics for all variables used in the analysis are reported in Table 1. The distribution of participants with an SDQ total score above ten and an SDQ total score of ten and below according to gender is presented in Table 1. The distribution of scores according to gender is shown in Fig. 2. Table 1 Descriptive and gender distributions Distributions by gender Variable Gender n Mean SD Skewness Kurtosis SDQ total >10 Girl 216 16 4 0.688 -0.425 Boy 339 15.3 4.3 0.975 -0.263 SDQ total ≤10 Girl 622 5.79 2.8 -0.234 -0.91 Boy 973 5.92 2.9 -0.34 -0.975 SDQ ext total >10 Girl 216 6.42 2.6 0.305 0.166 Boy 339 5.7 2.2 0.367 -0.035 SDQ int total >10 Girl 216 4.56 1.7 0.513 -0.01 Boy 339 5.33 2.2 0.541 0.484 Overall sample — n Mean SD Skewness Kurtosis SDQ total — 2150 8.38 5.4 0.952 0.871 SDQ internalization — 2150 2.85 2.1 0.918 1.104 SDQ externalization — 2150 3.29 2.4 0.974 0.994 SDQ total> 10 — 555 15.6 4.2 0.856 -0.372 Note : SDQtotal > 10: Participants with an SDQ total score above 10; SDQtotal ≤ 10: Participants with SDQ total score 10 and below; SDQexttotal > 10: Participants with SDQ externalization score above 10; SDQinttotal > 10: Participants with SDQ internalization score above 10. According to the results of the analyses, we determined that a total of 555 participants—216 girls and 339 boys, had a score higher than the cutoff score (> 10) determined from the SDQ total score. On the other hand, 1595 participants—622 girls and 973 boys—had scores lower than this score. Considering these results, we invited participants with lower cutoff scores to the second study and participants with higher cutoff scores to the third study of our experiment. Stage 2 Participants In this stage of our study, we conducted a pilot study with 50 (Mean age = 10.94, SD = 0.76) participants with an SDQ total score of 10 or less in our previous stage (stage 1). These 50 children were included in this stage voluntarily, and none of them were followed up with a psychiatric diagnosis or were taking psychotropic drugs. This stage of the study was conducted in November 2023. Measurements Empathy We aimed to ensure that the six videos (two each for happiness, sadness, and fear) reflect the target emotions consistently for our upcoming study). We used scenes from Harry Potter film, previously shown to accurately convey these emotions [ 60 ]. Participants answered questions about the main characters’ emotions in each clip for cognitive empathy and their own emotions while watching each clip for affective empathy. Responses were coded by a psychiatrist and a psychologist using the Cardiff Empathy Scoring System [ 68 ]. Cognitive empathy scores ranged from 0 to 9 and affective empathy scores from 0 to 7, with higher scores indicating greater empathy. Procedure Upon arriving at the school, participants were seated at a table with a 14.1-inch computer screen and a standard Turkish keyboard, positioned approximately 30 cm away from them. All tests were conducted in the same room at a constant temperature (24°C). Before watching the videos, the participants were informed about the process in detail and addressed their possible concerns. Participants watched 6 videos (Happy1, Happy2, Sad1, Sad2, Fear1, Fear2). At the end of each video, two raters coded the participants' responses using the Cardiff Empathy Scoring System. This stage took approximately 25–30 minutes for each participant. Statistical Approach All statistical analyses were performed using JASP 0.18.1 software. At this stage, we calculated the Krippendorff alpha [ 69 ] and Fleiss’ kappa [ 70 ] coefficients to assess the interrater reliability of the participant’s responses to each video clip (see Table 2). In addition, we used a dependent sample t-test to test whether the two videos corresponding to the target emotions were similar (see Table 3). Results Table 2 shows the mean, standard deviation, and video length. Additionally, Table 3 shows the skewness, kurtosis, interrater reliability scores, and cognitive and affective empathy scores for each clip by target emotion. The distribution of empathy scores according to gender is shown in Fig. 3. Table 2 Descriptive statistics (Stage 2) Target Emotion Clip no Mean SD Length C A C A Happiness 1 8.14 4.23 0.50 0.48 1.41 2 8.17 4.28 0.45 0.50 1.31 Sadness 1 8.38 3.13 0.56 0.78 1.17 2 8.44 3.20 0.55 0.72 1.00 Fear 1 8.28 3.15 0.55 0.56 1.44 2 8.37 3.26 0.52 0.55 2.26 Note : C: Cognitive Empathy; A: Affective Empathy To examine the reliability of the scores of the raters in the pilot study, we calculated the Krippendorff alpha and Fleiss kappa values for each of the six videos. As a result of these analyses, we determined that the interrater reliability coefficients for all videos were sufficient (see Table 3). Table 3 Inferential statistics (Stage 2) Target Emotion Clip no Skewness Kurtosis Krippendorff Fleisss' C A C A C A C A Happiness 1 -0.230 0.601 0.134 -0.215 0.560 0.954 0.559 0.953 2 0.083 0.382 0.648 -0.643 0.650 0.915 0.653 0.914 Sadness 1 -0.114 0.818 -1.183 0.870 0.854 0.866 0.852 0.865 2 -0.233 0.949 -1.114 1.324 0.925 0.849 0.924 0.847 Fear 1 0.029 0.168 -0.615 -0.369 0.743 0.696 0.846 0.693 2 0.106 0.227 -1.017 -0.258 0.960 0.767 0.960 0.764 Note : C: Cognitive Empathy; A: Affective Empathy The dependent sample t-test showed that the two clips corresponding to the target emotions did not significantly differ from each other (p > .05; see Table 4). Thus, the two clips per target emotion were similar for cognitive and affective empathy. Table 4 Dependent sample t-test results Variable df t p 95% CI LL UL Cognitive Happy 49 − .596 .554 -0.131 0.071 Cognitive Sad 49 -1.950 .057 -0.121 0.001 Cognitive Fear 49 -2.037 .051 -0.174 0.005 Affective Happy 49 -1.698 .096 -0.109 0.009 Affective Sad 49 -1.414 .164 -0.169 0.029 Affective Fear 49 -1.669 .102 -0.242 0.022 Stage 3 Participants In this stage of our study, we included 170 participants (Mean age = 10.94, SD = 0.76) with an SDQ total score of 11 or above from our previous stage (Stage 1). Initially, 278 of the 555 eligible participants agreed to join. We excluded 90 participants due to psychotropic medication use or psychiatric diagnosis, and 18 were unable to complete the trial, leaving170 participants for the analyses. Measurements State Empathy We used the six videos we pilot-tested in our previous stage (Stage 2). Participants watched six videos, two corresponding to the target emotion (Happiness, Sadness, Fear). In the same way as the procedure we used in our pilot study, all participants were asked questions about the main characters' emotions in each clip for cognitive empathy and their own emotions while watching each clip for affective empathy. Participants' responses were coded by one psychiatrist and one psychologist using the Cardiff Empathy Scoring System [ 68 ]. Cognitive empathy scores ranged between 0 and 9, while affective empathy scores ranged from 0 to 7, with higher scores indicating increased levels of empathy. State Empathy We used the six videos we pilot-tested in our previous stage (Stage 2). Participants watched six videos, two corresponding to the target emotion (Happiness, Sadness, Fear). In the same way as the procedure we used in our pilot study, all participants were asked questions about the main characters' emotions in each clip for cognitive empathy and their own emotions while watching each clip for affective empathy. Participants' responses were coded by one psychiatrist and one psychologist using the Cardiff Empathy Scoring System [ 68 ]. Cognitive empathy scores ranged between 0 and 9, while affective empathy scores ranged from 0 to 7, with higher scores indicating increased levels of empathy. Working Memory Here, we used the digit span task of the Wechsler Intelligence Scale for Children, WISC-R [ 71 ] to assess participants' working memory performance. In this study, both forward and backward-digit span tests were employed. However, we only used backward scores to evaluate working memory. This task was administered by a researcher who was trained as a WISC-R applicator. The researcher verbally presented the stimuli to the participants using a standardized form and instructions and scored the responses. Increasing scores on this measure were considered to increase working memory performance. Inhibition Here, we used the Stroop TBAG form within the scope of the Bilnot Battery to assess the inhibition skills of the participants. This form combines the original Stroop form [ 72 ] and the Victoria form [ 73 ]. The adaptation of the Stroop TBAG to Turkish culture was conducted by Karakaş et al. [ 74 ]. In this study, it was reported that the scale provided sufficient reliability. In our study, the Stroop TBAG test was administered to the participants using 14 cm × 21.5 cm stimulus cards and standard instructions. Participants' responses to the cards were coded by the researcher who had training on the Stroop TBAG applicator. A decrease in the scores obtained from this measure indicates an increase in inhibition skills. Questionnaires Externalizing and Internalizing Symptoms Here, the participants' externalizing and internalizing scores were created using the SDQ scores previously completed by the participants' parents (Stage 1). Trait Empathy In this stage, we used the Empathic Tendency Scale for Children and Adolescents to evaluate participants' empathic tendencies. The scale was developed by Kaya and Siyez [ 75 ] and this paper-and-pencil scale consists of 13 items scored on a 4-point Likert scale (1 = Not at all suitable for me, 4 = Completely suitable for me). It includes 7 items for affective empathy and 6 for cognitive empathy. Higher scores indicate greater empathic tendencies. In the original study, Cronbach's alpha internal consistency coefficients were .79 for affective empathy and .72 for cognitive empathy. In the current study, coefficients were .85 for cognitive empathy, .86 for affective empathy, and .91 for the overall scale. Procedure Participants were taken to a separate room when they arrived at the school. All tests were conducted in the same room at a constant temperature (24°C). Working memory and inhibition measurements were completed first. The participant and the researcher sat at opposite ends of a table, and these two measurements were completed. These two measurements took an average of 10–15 minutes for each participant. Afterwards, the participants were seated at a table with a 14.1-inch computer screen and a standard Turkish keyboard. The computer screen was positioned so that the participants sat approximately 30 cm away. Participants watched six videos in sequence on the computer screen; two raters coded the participants' responses using the Cardiff Empathy Scoring System. Finally, the participants completed the Empathic Tendency Scale for Children and Adolescents. In total, this stage took approximately 45–60 minutes for each participant. Statistical Approach All the statistical analyses were performed using JASP 0.18.1 software. At this stage, we calculated the Krippendorff alpha [ 69 ] and Fleiss’ kappa [ 70 ] coefficients to assess the interrater reliability of the participant’s responses to each video clip (see Table 6). First, we conducted a regression analysis to examine the relationship between state empathy and trait empathy scores. In addition, Pearson correlations were used to determine the relationships between working memory, inhibition, externalization, and internalization. Furthermore, multiple regression analyses were employed to assess the contribution of working memory, inhibition, externalization, and internalization in explaining cognitive and affective empathy. Multiple regression analyses were performed for cognitive (Model 1) and affective (Model 2) empathy. Finally, we used a one-way analysis of variance (ANOVA) to determine whether there was a difference between the empathy scores of the participants in the pilot study and the empathy scores in this phase. Results The mean and standard deviation values of the videos used in the study are presented in Table 5, the skewness and kurtosis values corresponding to each video, and the Krippendorff alpha and Fleiss' kappa values calculated for each video are presented in Table 6. Furthermore, Table 7 shows the relationships between the research variables. As a result of the analyses, we concluded that the interrater reliability values for all of the videos used in the study were acceptable. Additionally, the distribution of cognitive and affective empathy scores in Stage 3 according to gender is shown in Fig. 4. Table 5 Mean and standard deviation values for the videos Target Emotion Clip no Mean SD C A C A Happiness 1 6.00 4.95 1.95 0.90 2 6.16 4.35 1.89 1.28 Sadness 1 6.52 3.13 2.10 0.83 2 6.40 3.47 1.94 0.79 Fear 1 6.63 3.28 1.86 0.95 2 6.71 3.13 1.90 0.87 Note : C: Cognitive Empathy; A: Affective Empathy To examine the reliability of the scores of the raters in this stage of the study, we calculated Krippendorff’s alpha and Fleiss’ kappa values for each of the six videos. As a result of these analyses, we determined that the interrater reliability coefficients for all videos were sufficient (see Table 6). Table 6 Skewness, kurtosis and rater reliability values for each clip Target Emotion Clip no Skewness Kurtosis Krippendorff Fleisss' C A C A C A C A Happiness 1 − .986 − .165 .756 − .681 0.547 0.683 0.545 0.682 2 -1.153 .433 1.216 -1.187 0.730 0.788 0.729 0.788 Sadness 1 -1.057 .793 .419 .509 0.764 0.791 0.763 0.790 2 − .864 .539 .470 .084 0.901 0.762 0.901 0.761 Fear 1 -1.331 .190 1.702 − .784 0.867 0.967 0.867 0.967 2 -1.296 .349 1.610 − .556 0.905 0.763 0.905 0.762 Note : C: Cognitive Empathy; A: Affective Empathy Trait empathy and state empathy incongruity Cognitive empathy scores assessed with the scale did not predict cognitive empathy scores coded with the Cardiff system ( β = 0.072, t (169) = 0.934, p > .05). Similarly, affective empathy scores assessed with the scale did not predict affective empathy scores coded with the Cardiff system ( β = -0.045, t (169) = -0.585, p > .05). Therefore, we concluded that empathic tendencies assessed with the scale are different from those assessed with performance tests. Consequently, we did not include trait affective or trait cognitive scores in further analyses. Relationships between study variables An examination of the relationships between the research variables revealed a negative relationship between cognitive and affective empathy ( r = − .70, p < .05), a negative relationship between affective empathy and externalization ( r = − .19, p < .05), a positive relationship between working memory and cognitive empathy ( r = .26, p < .05), a positive relationship between inhibition and internalization ( r = .16, p < .05) and a positive relationship between internalization and externalization ( r = .24, p < .05)(see Table 7). Table 7 Relationships between study variables Variable 1 2 3 4 5 1. Affective 1 2. Cognitive − .70 ** 1 3.Working memory − .15 .26 ** 1 4.Stroop − .15 − .005 − .02 1 5. Internalization − .06 .05 .08 .16 * 1 6. Externalization − .19 * − .13 .04 .005 .24 ** Note : * p < .05; ** p < .01 Comparison of empathy scores between groups The ANOVA results showed that cognitive empathy [ f (1,218) = 2168.27, p < .001, n p 2 = 0.900]and affective empathy [ f (1,218) = 122.44, p < .001, n p 2 = 0.360] differed significantly according to the group variable (stage 2 vs. stage 3). The descriptive statistics for both ANOVAs are presented in Table 8. In addition, Fig. 5 provides a visualization of the ANOVA results. Table 8 ANOVA results Variable Group n Mean SE 95% CI for mean difference Lower Upper Cognitive Empathy Stage 2 50 8.29 0.06 8.126 8.467 Stage 3 170 3.72 0.05 3.629 3.814 Affective Empathy Stage 2 50 3.54 0.05 3.093 3.99 Stage 3 170 6.4 0.14 6.163 6.65 Predictors of cognitive and affective empathy Cognitive empathy Working memory ( β = 0.261, t (169) = 3.507, p < .05) and externalization ( β = -0.157, t (169) = -2.049, p .05) and internalization ( β = 0.065, t (169) = 0.830, p > .05) did not significantly predict cognitive empathy. Moreover, the full model was statistically significant ( F (4,169) = 4.150, p = 0.003, R 2 = 0.091) (see Table 9, Fig. 6). Affective empathy Externalization ( β = -0.193, t (169) = -2.502, p .05), inhibition ( β = --0.152, t (169) = -2.001, p > .05), and internalization ( β = 0.018, t (169) = 0.229, p > .05) did not significantly predict affective empathy. Moreover, the full model was statistically significant ( F (4,169) = 3.571, p = 0.008, R 2 = 0.080) (see Table 9, Fig. 6). Table 9 Multiple regression predicting cognitive and affective empathy for working memory, inhibition, internalization, and externalization Variable Model1 Model 2 Cognitive Empathy Affective Empathy B SE β t p B SE β t p Constant 10.919 0.553 15.578 1.354 Working memory 1.937 0.553 0.261 ** 3.507 .001 -0.389 0.202 -0.144 -1.924 .056 Inhibition -0.002 0.024 -0.008 -0.102 .919 -0.018 0.009 -0.152 -2.001 .051 Internalization 0.133 0.160 0.065 0.830 .407 0.013 0.059 0.018 0.229 .819 Externalization -0.283 0.138 -0.157 * -2.049 .042 -0.127 0.051 -0.193 * -2.502 .013 Note *p < 0.05, **p < 0.001. B = unstandardized regression coefficient. β = standardized coefficient Discussion 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. Conclusion To our knowledge, this is the first study to evaluate the relationship between internalizing and externalizing symptoms, executive functions (such as inhibition and working memory), and cognitive and affective empathy in a community sample of adolescents. By evaluating both symptom types separately, even in children with psychiatric symptoms, we achieved a detailed analysis of their interaction with empathy components. Our findings are consistent with the literature that executive functions and cognitive empathy are more closely related than affective empathy [ 13 , 21 , 36 ]. Executive function deficits are developmental risk factors that can lead to emotion regulation difficulties and externalizing disorders due to inadequate top-down regulation of subcortical regions [ 87 – 89 ]. This supports our argument that executive functions are linked to empathy, particularly in the context of internalizing symptoms. The negative relationship between externalizing symptoms and both cognitive and affective empathy in our study is consistent with previous clinical research [ 38 , 60 , 61 ]. However, unlike some studies, we did not find significant positive associations between internalizing symptoms and affective empathy [ 14 , 48 , 90 ]. Our results showed a negative but non-significant relationship between internalizing symptoms and affective empathy, which are consistent with some other studies that found no significant linear relationship [ 47 ] or a quadratic relationship for cognitive empathy [ 44 ] This study was conducted with high-risk children who had not yet received a psychiatric diagnosis. The authors suggested that internalizing symptoms might impair social interpretation and empathy due to a self-focused state affecting social experiences and relationships [ 77 , 91 ]. Similarly, our study found empathy deficits in children with psychiatric symptoms compared to those in the pilot study. Additionally, the higher number of children with externalizing symptoms in our sample may have influenced the observed relationships. Disorders like conduct disorder and ADHD have been shown to negatively relate to affective empathy [ 60 , 61 , 82 ] The presence of children with comorbid internalizing and externalizing disorders may have also affected our results. Further studies examining the effects of such comorbidities, common in adolescents [ 92 ], will help clarify these relationships. Declarations Data Availability The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. Acknowledgements We would like to express our sincere appreciation to all the participants who generously shared their time and provided valuable insights for this study. We also extend our gratitude to the school principals for their support in facilitating the data collection process. Funding The authors did not receive support from any organization for the submitted manuscript. Ethics approval and consent to participate This study was conducted in accordance with the permission obtained from the ethics committee of Toros University (2023/127). Written informed consent was obtained from a parent or legal guardian, followed by written assent from the participants. Consent for publication Not applicable. Competing interests The authors declare no competing interests. References Blakemore, S. J., & Choudhury, S. Development of the adolescent brain: Implications for executive function and social cognition. J. Child Psychol. Psychiatry . 47 (3‐4), 296-312 (2006). Ghasemian, A., & Venkatesh, G. K. Evaluate the effectiveness of life skills training on development of autonomy in adolescent students: A comparative study. IJPP 8 (1) (2017). Somerville, L. H. The teenage brain: Sensitivity to social evaluation. Curr. Dir. Psychol. Sci. 22 (2), 121-127 (2013). Farrell, A. H., & Vaillancourt, T. 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Behavioral inhibition and anxiety: The moderating roles of inhibitory control and attention shifting. J. Abnorm. Child Psychol. 39 (5), 735–747 (2011). Banerjee, R., & Henderson, L. Social–cognitive factors in childhood social anxiety: A preliminary investigation. Soc. Dev. 10 (4), 558–572 (2001). Colonnesi, C., Nikolić, M., de Vente, W., & Bögels, S. M. Social anxiety symptoms in young children: Investigating the interplay of theory of mind and expressions of shyness. J. Abnorm. Child Psychol. 45 , 997-1011 (2017). Finsaas, M. C., Bufferd, S. J., Dougherty, L. R., Carlson, G. A., & Klein, D. N. Preschool psychiatric disorders: Homotypic and heterotypic continuity through middle childhood and early adolescence. Psychol. Med . 48 (13), 2159-2168 (2018). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 28 Nov, 2024 Read the published version in BMC Psychiatry → Version 1 posted Editorial decision: Revision requested 29 Jul, 2024 Editor assigned by journal 26 Jul, 2024 Submission checks completed at journal 26 Jul, 2024 First submitted to journal 25 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4801384","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":333184229,"identity":"efc01c11-a273-4f03-9f97-2578875aca60","order_by":0,"name":"Onat Yetim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYBADHgb2BiBlYEGUakagWgMeBp4DIC0SxGthYJBIAHGI0MIv3fz8MU/FHxndmc+vbvhRIMHA396dgFeL5Jxjhs08Zwx4zG7nlN3sATpM4szZDXi1GNxIMGzmbQNrSbvBA9RiIJFLSEv6x2bef0AtN8+k3fxDnJYcoC0NQC032I/dJsoWyRk5hTPnHDPmMTuTw3ZbxkCCh6Bf+CXSN3x4UyNnb3b8+LObb/7YyPG39+LXAgJMPGCKxwBMElQOAow/wBT7A6JUj4JRMApGwcgDAPUdRu0O2D5nAAAAAElFTkSuQmCC","orcid":"","institution":"Toros University Bahçelievler district Mersin","correspondingAuthor":true,"prefix":"","firstName":"Onat","middleName":"","lastName":"Yetim","suffix":""},{"id":333184230,"identity":"1e8171f3-7572-458a-96d1-e163342b133c","order_by":1,"name":"Resul Çakır","email":"","orcid":"","institution":"Toros University Bahçelievler district Mersin","correspondingAuthor":false,"prefix":"","firstName":"Resul","middleName":"","lastName":"Çakır","suffix":""},{"id":333184231,"identity":"ed536026-1bd3-49c2-b26c-64d35f20650b","order_by":2,"name":"Lut Tamam","email":"","orcid":"","institution":"Çukurova University Balcalı Adana","correspondingAuthor":false,"prefix":"","firstName":"Lut","middleName":"","lastName":"Tamam","suffix":""}],"badges":[],"createdAt":"2024-07-25 11:09:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4801384/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4801384/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12888-024-06324-8","type":"published","date":"2024-11-28T15:57:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":63806770,"identity":"4889b9fe-90c9-4a4f-b81d-5d5778558ad5","added_by":"auto","created_at":"2024-09-02 13:40:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":266087,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic diagram of the study.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4801384/v1/7bd0391445c7e591e0db6d7b.png"},{"id":63806775,"identity":"d3c1a76e-7521-4841-a803-ccbebb2010cf","added_by":"auto","created_at":"2024-09-02 13:40:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":801361,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of internalization and externalization according to gender\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4801384/v1/66ed3991a8e8cc6b7a4830d1.png"},{"id":63806774,"identity":"a1f6d565-5f08-4073-91b6-ef432c493ec0","added_by":"auto","created_at":"2024-09-02 13:40:25","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":146223,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of cognitive and affective empathy in the pilot study according to gender\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-4801384/v1/a538dd5e2b1c2d5e70eb69da.png"},{"id":63808492,"identity":"180a8bf0-ca95-4fcd-b0eb-0056aa666475","added_by":"auto","created_at":"2024-09-02 13:48:25","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":141953,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of cognitive and affective empathy in Stage 3 according to gender\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-4801384/v1/19e6cf31db6dc4ecbc29ace4.png"},{"id":63806777,"identity":"5ba40635-dbad-497e-90ec-5072486525a6","added_by":"auto","created_at":"2024-09-02 13:40:25","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":129108,"visible":true,"origin":"","legend":"\u003cp\u003eANOVA results visualization\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-4801384/v1/dc8b9083be1be5ee5f37a0dd.png"},{"id":63806768,"identity":"33506006-3e41-428b-a5c3-666156e017da","added_by":"auto","created_at":"2024-09-02 13:40:25","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":135831,"visible":true,"origin":"","legend":"\u003cp\u003eVisual representation of multiple regressions\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-4801384/v1/a5e56ad685dfb6b169172a9d.png"},{"id":70388694,"identity":"1af12ace-5bf6-4df8-a5aa-335ea7d79936","added_by":"auto","created_at":"2024-12-02 17:26:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3234348,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4801384/v1/bda8e47b-463e-439e-a846-f8f96d6f9667.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Relationships between Empathy, Executive Functions, and Internalizing and Externalizing Symptoms in Early Adolescents","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAdolescence, characterized by the increased significance of social interaction, is a critical age for both empathy and executive functions, and neural and behavioral alterations occur during this period [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Empathy skills can be crucial at these ages [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], and are affected by and individual’s cognitive abilities [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. One reason for this effect could be that the transition from childhood to adulthood is accompanied by major changes in the brain, specifically significant neural changes in the prefrontal cortex that underlie executive functions and empathy [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDuring early adolescence, individuals often encounter high levels of stress stemming from acute daily stressors, family dysfunction, or economic problems [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A large body of evidence indicated that many psychosocial factors (e.g., adverse childhood experiences and trajectories and trauma) were found to be associated with both internalizing symptoms, such as anxiety and depression [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and externalizing symptoms, such as aggression and conduct problems [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In summary, considering the relationships between executive functions and empathy [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and between symptoms of internalization [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] and symptoms of externalization [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], executive functions and these psychopathological symptoms may predict an individual's empathic tendency.\u003c/p\u003e\n\u003ch3\u003eEmpathy\u003c/h3\u003e\n\u003cp\u003eEmpathy, as an umbrella term, is defined as the ability to understand, experience, and respond to the emotional state of another human being [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Most researchers consider empathy a multifaceted construct, primarily encompassing cognitive empathy, defined as the ability to understand and consider the emotional states of others, and affective empathy, defined as the ability to share and experience the emotions of another person [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe essential components of affective empathy emerge in children very early [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Concerning affective empathy, cognitive empathy skills also develop at 4–5 years of age. The development of cognitive empathy skills continues in early and middle childhood in conjunction with the development of frontotemporal and parietal regions [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In middle and early adolescence, cognitive empathy skills increase with age in parallel with the maturation of executive function skills [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eLinking Empathy to Executive Functioning\u003c/h2\u003e \u003cp\u003eExecutive functioning (EF) is an umbrella term for higher cognitive functions such as working memory, inhibition, and cognitive flexibility [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Studies conducted on adults often focus on these three dimensions of executive functions. However, during early and middle childhood, executive functions show linear development and are evaluated as one-dimensional [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In adolescence, the development of the prefrontal cortex leads to the maturation of executive functions [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Studies on executive functions in adolescence show differences. While some studies support a highly interrelated three-factor structure in children aged 8–13 years [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], other studies emphasize that the two-factor (inhibition and working memory) executive function model is valid in children aged 5–13 years, while the three-factor model (inhibition, set switching, and working memory) emerges after the age of 15 [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eExecutive functions are a fundamental component of cognitive empathy [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Studies show that various subcomponents of executive functions, such as working memory and cognitive flexibility, contribute differently to empathy, influencing how we interpret and predict others' behaviors 32]. While inhibition helps to suppress our automatic responses, working memory helps to preserve emotional processing. When we empathize with others, inhibition helps us to prevent emotional contamination and regulate our emotions as we manage our concerns for others. As cognitive abilities, EF can influence various aspects of social cognition, including both cognitive and affective empathy [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEmpathy is one of the motivating forces behind our social behavior [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Across both evolution and development, early arising empathic capacities such as experience sharing are later layered with the ability to draw specific attributions about what others feel, want, and need, even when the targets’ experience diverges from the observers’ own [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. These advances in social cognition allow children to overcome obstacles and socially modulate their emotions [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTwo interrelated processes, bottom-up (involves the sensory-driven, automatic response to external stimuli) and top-down (involves higher-level cognitive functions, such as reasoning, expectations, and prior knowledge) information processing, are thought to underpin empathy [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Executive functions may function to regulate our empathic approach toward others [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. A recent meta-analysis revealed that empathy is strongly associated with executive functions, emphasizing that cognitive empathy is more closely related to executive functions than affective empathy [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. This study revealed strong relationships between cognitive empathy and inhibition, working memory, and cognitive flexibility, whereas affective empathy was only associated with inhibition [see also, 37]. However, studies also show that executive functions are more strongly associated with affective empathy than with cognitive empathy [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe inclusion of varying age groups and psychopathologies in studies on children and adolescents may affect the results. Our study will assess relevant relationships in a community sample of 10-12- year-olds with psychiatric symptoms but without clinical diagnoses or psychotropic medication.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eLinking Empathy to Internalizing Symptoms\u003c/h2\u003e \u003cp\u003eThe results of previous studies on empathy and internalizing symptoms suggest that high levels of affective empathy can include negative aspects such as emotional contagion, where a person’s emotions are strongly influenced by others, increasing susceptibility to others' distress and potentially heightening internalizing symptoms [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. However, children with internalizing symptoms often experience intense adverse effects, leading to inflexible processing of social and emotional information, which can worsen interpersonal difficulties, especially in those with anxiety disorders [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Impaired social functioning is also common in individuals with clinical and subthreshold depression symptoms [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHigh levels of affective empathy are thought to lead to internalizing disorders such as depression and anxiety in children and adolescents [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. However, findings from studies of the relationship between empathy and internalizing symptoms in children and adolescents appear to be inconsistent. For example, in a study of 170 children and adolescents aged 9–15 years, no significant relationship was found between levels of affective empathy and symptoms of depression [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. In another study, high levels of empathic distress and empathic concern, which are components of affective empathy, were found to be significantly associated with internalizing symptoms such as depression and anxiety disorders in adolescents aged 13–16 [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLow cognitive empathy is significantly linked to anxiety symptoms in children aged 6–11 years [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. A recent study of 127 children aged 9–10 years found that affective empathy, emotional sharing, and empathic distress were positively associated with internalizing symptoms, especially social anxiety disorder, but cognitive empathy showed no significant relationship with internalizing symptoms [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Another study of 1,223 adolescents (average age 10.5 years) reported that low cognitive empathy may increase the risk of depression, though moderate to high cognitive empathy was not significantly associated with depression symptoms [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe interactions between empathy skills and internalizing symptoms are closely related to emotion regulation skills [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Since deficits in executive functioning can lead to challenges in emotion regulation [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e], difficulties in the sociocognitive process—such as cognitive distortions, attentional biases—found in internalizing disorders may also negatively affect children's empathy skills [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. However, in light of recent studies, we predicted that internalizing symptoms would be positively associated with affective empathy but not with cognitive empathy in our study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eLinking Empathy to Externalizing Symptoms\u003c/h2\u003e \u003cp\u003eEmpathy is related to various contextual factors, early childhood experiences, and social behaviors. Therefore, children with psychopathologies often exhibit deficits in empathy, as these factors can influence the development and expression of empathetic abilities [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Studies conducted with children and adolescents highlight that there are significant associations between externalizing symptoms such as conduct disorder, oppositional defiant disorder, aggressive behavior and callous, unemotional traits and low levels of empathy [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Affective and cognitive empathy skills may prevent the development of externalizing symptoms by increasing positive social behaviors [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. A study of 507 adolescents aged 12–17 that high affective and cognitive empathy levels were negatively associated with externalizing symptoms [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eReduced or absent empathy forms the basis of conduct disorder, characterized by disruptive and antisocial behavior [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. A recent study revealed that 92 children with externalizing symptoms such as conduct disorder, with an average age of 9 years, had deficits in cognitive and affective empathy skills compared to the control group [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. However, deficits in both affective and cognitive components of empathy are also observed in children diagnosed with combined attention deficit hyperactivity disorder (ADHD), which is often associated with disruptive behavior disorders [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese deficits in empathy may be partly explained by the impulsivity typically observed in children with externalizing symptoms such as ADHD. Dysfunction in frontostriatal brain networks appears to impact both empathic processing and executive dysfunction [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. It has been suggested that the behavioral inhibition deficits, as a core symptom in children with ADHD, may impair both impulsivity and cognitive skills. However, the extent to which children's empathic abilities are affected remains unresolved [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. Given these data, our study will also consider executive function deficits when assessing the relationships between externalizing symptoms and affective and cognitive empathy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eThe Current Study\u003c/h2\u003e \u003cp\u003eDespite the available research on the associations between empathy, executive functioning, and psychiatric symptoms in children and adolescents that have been explored in the literature, the mechanism driving these relationships is still not well understood. Based on the literature, we hypothesized that (a) executive functioning would be more strongly related to cognitive empathy than to affective empathy, (b) internalizing symptoms would be positively correlated with affective empathy but (c) not with cognitive empathy, and (d) externalizing symptoms would negatively related to both affective and cognitive empathy.\u003c/p\u003e \u003c/div\u003e\n\n \u003cp\u003e \u003c/p\u003e "},{"header":"General Procedures","content":"\u003cp\u003eAn exploratory quantitative research design guided the cross-sectional sampling method to recruit adolescents from diverse schools in Mersin, Turkey. Using a convenience sampling approach, potential participants at public schools in Mersin, were invited to participate in the research. Written informed consent was obtained from a parent or legal guardian, and participants also provided written assent. This study comprised three stages. In the first stage, we recruited 2,398 early adolescents and their parents. Parents evaluated their children using the Strengths and Difficulties Questionnaire (SDQ) parent form. After excluding 161 participants with more than 25% missing data and 87 based on Mahalanobis distance, we analyzed data from 2,150 participants.\u003c/p\u003e\u003cp\u003eIn the second stage, we selected participants with an SDQ total score of 10 or less. We conducted a pilot study to validate the film clips and the Cardiff empathy coding system for the next phase, using these participants as a comparison group. This phase included 50 participants, all of whom completed the measurements.\u003c/p\u003e\u003cp\u003e In the third stage, we included participants with an SDQ total score above 10. We assessed their empathic tendencies using the validated film clips and the Empathic Tendency Scale for Children and Adolescents. Participants also completed the digit span and Stroop tests. A schematic diagram of the study is shown in Fig.\u0026nbsp;1.\u003c/p\u003e\u003cp\u003e The present study complied with the regulations of the University Ethics Committee, and data collection was carried out between September 2023 and January 2024. The study was conducted in agreement with the Declaration of Helsinki.\u003c/p\u003e"},{"header":"Stage 1","content":"\u003cp\u003eIn the first stage, we conducted a screening study with the Strengths and Difficulties Questionnaire (SDQ) to determine which participants should be included in the later stages of our study. To achieve this, we collected data from the parents of children attending schools in Mersin, Turkey, which provided formal education and volunteered to participate in the study.\u003c/p\u003e\n\u003ch3\u003eMethod\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe sample of this stage consists of 2150 parents with children aged 10–12 years (mean = 11.14, SD = 0.70) who are enrolled in formal education.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eProcedures\u003c/h2\u003e \u003cp\u003e Written informed consent was obtained, followed by written permission from the participants’ parents. Parents who completed the consent form could read and write in their native language and volunteered to participate in this stage. They were included in the data collection process. The data were collected from 2398 parents, but after checking for invalid data, the number of participants was reduced to 2150. The Strengths and Difficulties Questionnaire (SDQ) was used for data collection.\u003c/p\u003e \u003cp\u003eIn this study, children with a total SDQ score above ten were invited to the third stage of our study, and children with a total SDQ score of 10 and below were invited to the second stage of our study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eMeasurements\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003eIndicators of Internalization and Externalization\u003c/h2\u003e \u003cp\u003eIn this stage, the Strengths and Difficulties Questionnaire (SDQ) parent form was used to determine the participants’ level of psychological problems. The Strengths and Difficulties Inventory was developed by Goodman [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e] to assess the emotional and behavioral problems of children aged 4–16 years. The scale comprises 25 items across five subdimensions: attention deficit and hyperactivity disorder, behavioral problems, emotional problems, peer problems, and social behaviors. Each subdimension yields a separate score, or a total difficulty score can be calculated. For this study, the strengths and difficulties inventory was evaluated under two subdimensions (internalization and externalization), following Goodman and Goodman's [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e] recommendation for community samples. Emotional symptoms and peer relationships were considered internalizing dimensions, with higher scores indicating greater internalizing symptoms. Behavioral problems and hyperactivity were considered externalizing dimensions, with higher scores indicating greater externalizing symptoms. The scale was standardized for Turkish by Güvenir et al. [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. In their study, Cronbach's alpha coefficients were .73, .65, .80, .37, and .73 for emotional, behavioral, attention deficit, peer problems, and social behavior subdimensions, respectively, with an overall score of .84. In the present study, the Cronbach's alpha coefficients were .69 for emotional symptoms, .70 for peer relations, .52 for behavioral problems, .58 for hyperactivity, .86 for prosocial behavior, .65 for internalization, .73 for externalization, and .82 for the total scale score.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Approach\u003c/h2\u003e \u003cp\u003eBefore the analysis, normality assumptions were tested using skewness and kurtosis scores. All variables’ skewness and kurtosis scores are within acceptable limits [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. All the statistical analyses were performed using JASP 0.18.1 software. At this stage, we used only descriptive and inferential statistical analysis methods to determine the children to be included in the different stages of our study. Thus, we obtained the total SDQ score of the children to be invited to the following stages and the internalization and externalization scores to be used in the following stages.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eResults\u003c/h3\u003e\n\u003cp\u003eDescriptive and inferential statistics for all variables used in the analysis are reported in Table\u0026nbsp;1. The distribution of participants with an SDQ total score above ten and an SDQ total score of ten and below according to gender is presented in Table\u0026nbsp;1. The distribution of scores according to gender is shown in Fig.\u0026nbsp;2.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive and gender distributions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e \u003cp\u003eDistributions by gender\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSkewness\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eKurtosis\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSDQ\u003csub\u003etotal \u0026gt;10\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGirl\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.688\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.425\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBoy\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e339\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.3\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.975\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.263\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSDQ\u003csub\u003etotal ≤10\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGirl\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e622\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.79\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.234\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.91\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBoy\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e973\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.92\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.34\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.975\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSDQ\u003csup\u003eext\u003c/sup\u003e\u003csub\u003etotal \u0026gt;10\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGirl\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.42\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.305\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.166\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBoy\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e339\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.7\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.367\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.035\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSDQ\u003csup\u003eint\u003c/sup\u003e\u003csub\u003etotal \u0026gt;10\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGirl\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.56\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.513\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.01\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBoy\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e339\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.33\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.541\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.484\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e \u003cp\u003eOverall sample\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e—\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSkewness\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eKurtosis\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSDQ\u003csub\u003etotal\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e—\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2150\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.38\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.4\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.952\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.871\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSDQ\u003csub\u003einternalization\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e—\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2150\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.85\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.918\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.104\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSDQ\u003csub\u003eexternalization\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e—\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2150\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.29\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.4\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.974\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.994\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSDQ\u003csub\u003etotal\u0026gt; 10\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e—\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e555\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.6\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.856\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.372\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNote\u003c/em\u003e: SDQtotal \u0026gt; 10: Participants with an SDQ total score above 10; SDQtotal ≤ 10: Participants with SDQ total score 10 and below; SDQexttotal \u0026gt; 10: Participants with SDQ externalization score above 10; SDQinttotal \u0026gt; 10: Participants with SDQ internalization score above 10.\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003eAccording to the results of the analyses, we determined that a total of 555 participants—216 girls and 339 boys, had a score higher than the cutoff score (\u0026gt; 10) determined from the SDQ total score. On the other hand, 1595 participants—622 girls and 973 boys—had scores lower than this score. Considering these results, we invited participants with lower cutoff scores to the second study and participants with higher cutoff scores to the third study of our experiment.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e \n\n \u003cp\u003e \u003c/p\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e\u003c/p\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003cdiv id=\"Sec30\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Stage 2","content":"\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eIn this stage of our study, we conducted a pilot study with 50 (Mean age = 10.94, SD = 0.76) participants with an SDQ total score of 10 or less in our previous stage (stage 1). These 50 children were included in this stage voluntarily, and none of them were followed up with a psychiatric diagnosis or were taking psychotropic drugs. This stage of the study was conducted in November 2023.\u003c/p\u003e\u003ch2\u003eMeasurements\u003c/h2\u003e\u003ch2\u003eEmpathy\u003c/h2\u003e\u003cp\u003eWe aimed to ensure that the six videos (two each for happiness, sadness, and fear) reflect the target emotions consistently for our upcoming study). We used scenes from Harry Potter film, previously shown to accurately convey these emotions [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Participants answered questions about the main characters’ emotions in each clip for cognitive empathy and their own emotions while watching each clip for affective empathy. Responses were coded by a psychiatrist and a psychologist using the Cardiff Empathy Scoring System [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. Cognitive empathy scores ranged from 0 to 9 and affective empathy scores from 0 to 7, with higher scores indicating greater empathy.\u003c/p\u003e\u003ch2\u003eProcedure\u003c/h2\u003e\u003cp\u003eUpon arriving at the school, participants were seated at a table with a 14.1-inch computer screen and a standard Turkish keyboard, positioned approximately 30 cm away from them. All tests were conducted in the same room at a constant temperature (24°C). Before watching the videos, the participants were informed about the process in detail and addressed their possible concerns. Participants watched 6 videos (Happy1, Happy2, Sad1, Sad2, Fear1, Fear2). At the end of each video, two raters coded the participants' responses using the Cardiff Empathy Scoring System. This stage took approximately 25–30 minutes for each participant.\u003c/p\u003e\u003ch2\u003eStatistical Approach\u003c/h2\u003e\u003cp\u003eAll statistical analyses were performed using JASP 0.18.1 software. At this stage, we calculated the Krippendorff alpha [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e] and Fleiss’ kappa [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e] coefficients to assess the interrater reliability of the participant’s responses to each video clip (see Table\u0026nbsp;2). In addition, we used a dependent sample t-test to test whether the two videos corresponding to the target emotions were similar (see Table\u0026nbsp;3).\u003c/p\u003e\u003ch3\u003eResults \u003c/h3\u003e\u003cp\u003eTable\u0026nbsp;2 shows the mean, standard deviation, and video length. Additionally, Table\u0026nbsp;3 shows the skewness, kurtosis, interrater reliability scores, and cognitive and affective empathy scores for each clip by target emotion. The distribution of empathy scores according to gender is shown in Fig.\u0026nbsp;3.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive statistics (Stage 2)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTarget Emotion\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eClip no\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLength\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHappiness\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.14\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.23\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.41\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.17\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.28\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.31\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSadness\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.38\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.13\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.17\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.44\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.20\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFear\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.28\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.15\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.44\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.37\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.26\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.26\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e \u003cem\u003eNote\u003c/em\u003e: C: Cognitive Empathy; A: Affective Empathy\u003c/p\u003e\u003cp\u003eTo examine the reliability of the scores of the raters in the pilot study, we calculated the Krippendorff alpha and Fleiss kappa values for each of the six videos. As a result of these analyses, we determined that the interrater reliability coefficients for all videos were sufficient (see Table\u0026nbsp;3).\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInferential statistics (Stage 2)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"10\"\u003e\u003c/colgroup\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTarget Emotion\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eClip no\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eSkewness\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eKurtosis\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eKrippendorff\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eFleisss'\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHappiness\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.230\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.601\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.134\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.215\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.560\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.954\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.559\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.953\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.083\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.382\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.648\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.643\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.650\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.915\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.653\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.914\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSadness\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.114\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.818\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.183\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.870\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.854\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.866\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.852\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.865\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.233\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.949\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.114\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.324\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.925\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.849\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.924\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.847\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFear\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.168\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.615\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.369\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.743\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.696\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.846\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.693\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.106\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.227\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.017\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.258\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.960\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.767\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.960\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.764\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e \u003cem\u003eNote\u003c/em\u003e: C: Cognitive Empathy; A: Affective Empathy\u003c/p\u003e\u003cp\u003eThe dependent sample t-test showed that the two clips corresponding to the target emotions did not significantly differ from each other (p \u0026gt; .05; see Table\u0026nbsp;4). Thus, the two clips per target emotion were similar for cognitive and affective empathy.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDependent sample t-test results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003edf\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLL\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUL\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive\u003csub\u003eHappy\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e− .596\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.554\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.131\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.071\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive\u003csub\u003eSad\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.950\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.057\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.121\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive\u003csub\u003eFear\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-2.037\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.051\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.174\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffective\u003csub\u003eHappy\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.698\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.096\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.109\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffective\u003csub\u003eSad\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.414\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.164\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.169\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffective\u003csub\u003eFear\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.669\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.102\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.242\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.022\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e"},{"header":"Stage 3","content":"\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eIn this stage of our study, we included 170 participants (Mean age = 10.94, SD = 0.76) with an SDQ total score of 11 or above from our previous stage (Stage 1). Initially, 278 of the 555 eligible participants agreed to join. We excluded 90 participants due to psychotropic medication use or psychiatric diagnosis, and 18 were unable to complete the trial, leaving170 participants for the analyses.\u003c/p\u003e\u003ch2\u003eMeasurements\u003c/h2\u003e\u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eState Empathy\u003c/h2\u003e \u003cp\u003eWe used the six videos we pilot-tested in our previous stage (Stage 2). Participants watched six videos, two corresponding to the target emotion (Happiness, Sadness, Fear). In the same way as the procedure we used in our pilot study, all participants were asked questions about the main characters' emotions in each clip for cognitive empathy and their own emotions while watching each clip for affective empathy. Participants' responses were coded by one psychiatrist and one psychologist using the Cardiff Empathy Scoring System [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. Cognitive empathy scores ranged between 0 and 9, while affective empathy scores ranged from 0 to 7, with higher scores indicating increased levels of empathy.\u003c/p\u003e \u003c/div\u003e\u003ch2\u003eState Empathy\u003c/h2\u003e\u003cp\u003eWe used the six videos we pilot-tested in our previous stage (Stage 2). Participants watched six videos, two corresponding to the target emotion (Happiness, Sadness, Fear). In the same way as the procedure we used in our pilot study, all participants were asked questions about the main characters' emotions in each clip for cognitive empathy and their own emotions while watching each clip for affective empathy. Participants' responses were coded by one psychiatrist and one psychologist using the Cardiff Empathy Scoring System [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. Cognitive empathy scores ranged between 0 and 9, while affective empathy scores ranged from 0 to 7, with higher scores indicating increased levels of empathy.\u003c/p\u003e\u003ch2\u003eWorking Memory\u003c/h2\u003e\u003cp\u003eHere, we used the digit span task of the Wechsler Intelligence Scale for Children, WISC-R [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e] to assess participants' working memory performance. In this study, both forward and backward-digit span tests were employed. However, we only used backward scores to evaluate working memory. This task was administered by a researcher who was trained as a WISC-R applicator. The researcher verbally presented the stimuli to the participants using a standardized form and instructions and scored the responses. Increasing scores on this measure were considered to increase working memory performance.\u003c/p\u003e\u003ch2\u003eInhibition\u003c/h2\u003e\u003cp\u003e Here, we used the Stroop TBAG form within the scope of the Bilnot Battery to assess the inhibition skills of the participants. This form combines the original Stroop form [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e] and the Victoria form [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]. The adaptation of the Stroop TBAG to Turkish culture was conducted by Karakaş et al. [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. In this study, it was reported that the scale provided sufficient reliability. In our study, the Stroop TBAG test was administered to the participants using 14 cm × 21.5 cm stimulus cards and standard instructions. Participants' responses to the cards were coded by the researcher who had training on the Stroop TBAG applicator. A decrease in the scores obtained from this measure indicates an increase in inhibition skills.\u003c/p\u003e\u003ch2\u003eQuestionnaires\u003c/h2\u003e\u003ch2\u003eExternalizing and Internalizing Symptoms\u003c/h2\u003e\u003cp\u003eHere, the participants' externalizing and internalizing scores were created using the SDQ scores previously completed by the participants' parents (Stage 1).\u003c/p\u003e\u003ch2\u003eTrait Empathy\u003c/h2\u003e\u003cp\u003eIn this stage, we used the Empathic Tendency Scale for Children and Adolescents to evaluate participants' empathic tendencies. The scale was developed by Kaya and Siyez [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e] and this paper-and-pencil scale consists of 13 items scored on a 4-point Likert scale (1 = Not at all suitable for me, 4 = Completely suitable for me). It includes 7 items for affective empathy and 6 for cognitive empathy. Higher scores indicate greater empathic tendencies. In the original study, Cronbach's alpha internal consistency coefficients were .79 for affective empathy and .72 for cognitive empathy. In the current study, coefficients were .85 for cognitive empathy, .86 for affective empathy, and .91 for the overall scale.\u003c/p\u003e\u003ch2\u003eProcedure\u003c/h2\u003e\u003cp\u003eParticipants were taken to a separate room when they arrived at the school. All tests were conducted in the same room at a constant temperature (24°C). Working memory and inhibition measurements were completed first. The participant and the researcher sat at opposite ends of a table, and these two measurements were completed. These two measurements took an average of 10–15 minutes for each participant. Afterwards, the participants were seated at a table with a 14.1-inch computer screen and a standard Turkish keyboard. The computer screen was positioned so that the participants sat approximately 30 cm away. Participants watched six videos in sequence on the computer screen; two raters coded the participants' responses using the Cardiff Empathy Scoring System. Finally, the participants completed the Empathic Tendency Scale for Children and Adolescents. In total, this stage took approximately 45–60 minutes for each participant.\u003c/p\u003e\u003ch2\u003eStatistical Approach\u003c/h2\u003e\u003cp\u003eAll the statistical analyses were performed using JASP 0.18.1 software. At this stage, we calculated the Krippendorff alpha [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e] and Fleiss’ kappa [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e] coefficients to assess the interrater reliability of the participant’s responses to each video clip (see Table\u0026nbsp;6). First, we conducted a regression analysis to examine the relationship between state empathy and trait empathy scores. In addition, Pearson correlations were used to determine the relationships between working memory, inhibition, externalization, and internalization. Furthermore, multiple regression analyses were employed to assess the contribution of working memory, inhibition, externalization, and internalization in explaining cognitive and affective empathy. Multiple regression analyses were performed for cognitive (Model 1) and affective (Model 2) empathy. Finally, we used a one-way analysis of variance (ANOVA) to determine whether there was a difference between the empathy scores of the participants in the pilot study and the empathy scores in this phase.\u003c/p\u003e\n\u003ch3\u003eResults\u003c/h3\u003e\n\u003cp\u003eThe mean and standard deviation values of the videos used in the study are presented in Table\u0026nbsp;5, the skewness and kurtosis values corresponding to each video, and the Krippendorff alpha and Fleiss' kappa values calculated for each video are presented in Table\u0026nbsp;6. Furthermore, Table\u0026nbsp;7 shows the relationships between the research variables. As a result of the analyses, we concluded that the interrater reliability values for all of the videos used in the study were acceptable. Additionally, the distribution of cognitive and affective empathy scores in Stage 3 according to gender is shown in Fig.\u0026nbsp;4.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean and standard deviation values for the videos\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTarget Emotion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eClip no\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHappiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSadness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eNote\u003c/em\u003e: C: Cognitive Empathy; A: Affective Empathy\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTo examine the reliability of the scores of the raters in this stage of the study, we calculated Krippendorff\u0026rsquo;s alpha and Fleiss\u0026rsquo; kappa values for each of the six videos. As a result of these analyses, we determined that the interrater reliability coefficients for all videos were sufficient (see Table\u0026nbsp;6).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSkewness, kurtosis and rater reliability values for each clip\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTarget Emotion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eClip no\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eSkewness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eKurtosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eKrippendorff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eFleisss'\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHappiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.986\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.756\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.681\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.547\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.683\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.545\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.682\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.153\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.433\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-1.187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.730\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.788\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.729\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.788\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSadness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.793\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.419\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.509\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.764\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.791\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.763\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.790\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.864\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.539\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.470\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.084\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.901\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.762\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.901\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.761\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.331\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.702\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.784\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.867\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.967\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.867\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.967\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.296\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.349\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.610\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.556\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.905\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.763\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.905\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.762\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eNote\u003c/em\u003e: C: Cognitive Empathy; A: Affective Empathy\u003c/p\u003e\n\u003ch3\u003eTrait empathy and state empathy incongruity\u003c/h3\u003e\n\u003cp\u003eCognitive empathy scores assessed with the scale did not predict cognitive empathy scores coded with the Cardiff system (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.072, \u003cem\u003et\u003c/em\u003e(169)\u0026thinsp;=\u0026thinsp;0.934, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05). Similarly, affective empathy scores assessed with the scale did not predict affective empathy scores coded with the Cardiff system (\u003cem\u003eβ\u003c/em\u003e = -0.045, \u003cem\u003et\u003c/em\u003e(169) = -0.585, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05). Therefore, we concluded that empathic tendencies assessed with the scale are different from those assessed with performance tests. Consequently, we did not include trait affective or trait cognitive scores in further analyses.\u003c/p\u003e\n\u003ch3\u003eRelationships between study variables\u003c/h3\u003e\n\u003cp\u003eAn examination of the relationships between the research variables revealed a negative relationship between cognitive and affective empathy (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.70, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05), a negative relationship between affective empathy and externalization (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.19, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05), a positive relationship between working memory and cognitive empathy (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.26, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05), a positive relationship between inhibition and internalization (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.16, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05) and a positive relationship between internalization and externalization (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.24, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05)(see Table\u0026nbsp;7).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRelationships between study variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Affective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Cognitive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.70\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.Working memory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.26\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.Stroop\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Internalization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.16\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Externalization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.19\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.24\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNote\u003c/em\u003e: *\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05; **\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec37\" class=\"Section2\"\u003e \u003ch2\u003eComparison of empathy scores between groups\u003c/h2\u003e \u003cp\u003eThe ANOVA results showed that cognitive empathy [\u003cem\u003ef\u003c/em\u003e(1,218)\u0026thinsp;=\u0026thinsp;2168.27, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, n\u003csub\u003e\u003cem\u003ep\u003c/em\u003e\u003c/sub\u003e\u003csup\u003e2\u003c/sup\u003e = 0.900]and affective empathy [\u003cem\u003ef\u003c/em\u003e(1,218)\u0026thinsp;=\u0026thinsp;122.44, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, n\u003csub\u003e\u003cem\u003ep\u003c/em\u003e\u003c/sub\u003e\u003csup\u003e2\u003c/sup\u003e = 0.360] differed significantly according to the group variable (stage 2 vs. stage 3). The descriptive statistics for both ANOVAs are presented in Table\u0026nbsp;8. In addition, Fig.\u0026nbsp;5 provides a visualization of the ANOVA results.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eANOVA results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e95% CI for mean difference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUpper\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCognitive Empathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStage 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.467\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStage 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.629\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.814\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAffective Empathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStage 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.093\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStage 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec38\" class=\"Section3\"\u003e \u003ch2\u003ePredictors of cognitive and affective empathy\u003c/h2\u003e \u003c/div\u003e \u003cdiv id=\"Sec39\" class=\"Section3\"\u003e \u003ch2\u003eCognitive empathy\u003c/h2\u003e \u003cp\u003eWorking memory (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.261, \u003cem\u003et\u003c/em\u003e(169)\u0026thinsp;=\u0026thinsp;3.507, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05) and externalization (\u003cem\u003eβ\u003c/em\u003e = -0.157, \u003cem\u003et\u003c/em\u003e(169) = -2.049, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05) were significant predictors of cognitive empathy. However, inhibition (\u003cem\u003eβ\u003c/em\u003e = -0.008, \u003cem\u003et\u003c/em\u003e(169) = -0.102, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05) and internalization (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.065, \u003cem\u003et\u003c/em\u003e(169)\u0026thinsp;=\u0026thinsp;0.830, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05) did not significantly predict cognitive empathy. Moreover, the full model was statistically significant (\u003cem\u003eF\u003c/em\u003e(4,169)\u0026thinsp;=\u0026thinsp;4.150, p\u0026thinsp;=\u0026thinsp;0.003, R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.091) (see Table\u0026nbsp;9, Fig.\u0026nbsp;6).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec40\" class=\"Section3\"\u003e \u003ch2\u003eAffective empathy\u003c/h2\u003e \u003cp\u003eExternalization (\u003cem\u003eβ\u003c/em\u003e = -0.193, \u003cem\u003et\u003c/em\u003e(169) = -2.502, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05) was a significant predictor of affective empathy. However, working memory (\u003cem\u003eβ\u003c/em\u003e = --0.144, \u003cem\u003et\u003c/em\u003e(169) = -1.924, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05), inhibition (\u003cem\u003eβ\u003c/em\u003e = --0.152, \u003cem\u003et\u003c/em\u003e(169) = -2.001, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05), and internalization (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.018, \u003cem\u003et\u003c/em\u003e(169)\u0026thinsp;=\u0026thinsp;0.229, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05) did not significantly predict affective empathy. Moreover, the full model was statistically significant (\u003cem\u003eF\u003c/em\u003e(4,169)\u0026thinsp;=\u0026thinsp;3.571, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.008, R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.080) (see Table\u0026nbsp;9, Fig.\u0026nbsp;6).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab9\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 9\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultiple regression predicting cognitive and affective empathy for working memory, inhibition, internalization, and externalization\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eModel1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c11\" namest=\"c7\"\u003e \u003cp\u003eModel 2\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eCognitive Empathy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c11\" namest=\"c7\"\u003e \u003cp\u003eAffective Empathy\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eSE\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eβ\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eSE\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003eβ\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.919\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.553\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15.578\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.354\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorking memory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.937\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.553\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.261\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.507\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.389\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-1.924\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e.056\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInhibition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.919\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-2.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e.051\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternalization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.065\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.830\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.407\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e.819\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExternalization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.157\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-2.049\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.051\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.193\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-2.502\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e.013\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eNote\u003c/strong\u003e \u003cp\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, **p\u0026thinsp;\u0026lt;\u0026thinsp;0.001. B\u0026thinsp;=\u0026thinsp;unstandardized regression coefficient. \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;standardized coefficient\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis 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.\u003c/p\u003e\n\u003ch3\u003eEmpathy and Internalizing Symptoms\u003c/h3\u003e\n\u003cp\u003eIn 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 [\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e] and Bray et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] 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.\u003c/p\u003e \u003cp\u003eIn 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 [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The authors stated that anxious children may be less capable of adequately sharing and responding appropriately in emotional situations. Morrison et al. [\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e] also reported that adults with social anxiety disorder had more difficulty indirectly sharing the positive emotions of others than healthy controls.\u003c/p\u003e \u003cp\u003eHowever, a study involving 127 children aged 9\u0026ndash;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 [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Another study of 170 children and adolescents aged 9\u0026ndash;15 found no significant relationships between affective empathy and depression symptoms [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven 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.\u003c/p\u003e \u003cp\u003eTone and Tully [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] 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 [\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e] 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.\u003c/p\u003e\n\u003ch3\u003eEmpathy and Externalizing Symptoms\u003c/h3\u003e\n\u003cp\u003eIn 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.\u003c/p\u003e \u003cp\u003eIn 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 [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Affective and cognitive empathy skills are thought to prevent the development of externalizing symptoms by increasing positive social behaviors [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Another study conducted with 507 adolescents aged 12\u0026ndash;17 years revealed that high levels of affective and cognitive empathy were negatively associated with externalizing symptoms [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eChildhood psychiatric disorders with externalizing symptoms, such as attention deficit hyperactivity disorder [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e] and disruptive behavior disorders [\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e] 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 [\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e] has led to the evaluation of empathy difficulties as a risk factor in the social development of children before the development of psychiatric disorders.\u003c/p\u003e \u003cp\u003eIn children with externalizing symptoms, difficulties in understanding and responding to the emotional states of others are associated with interpersonal and social problems [\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e]. These interpersonal and social problems negatively affect children's affective and cognitive empathy skills. Cox et al. [\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e] argued that the ratio of affective empathy to cognitive empathy is associated with externalizing symptoms such as trait aggression and impulsivity.\u003c/p\u003e \u003cp\u003eThese 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 [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, externalizing symptoms significantly predicted affective and cognitive empathy difficulties. In our sample of treatment-na\u0026iuml;ve 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.\u003c/p\u003e\n\u003ch3\u003eEmpathy and Executive Functions\u003c/h3\u003e\n\u003cp\u003eOur 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.\u003c/p\u003e \u003cp\u003eStudies 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 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA 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 [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. 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.\u003c/p\u003e \u003cp\u003eIt 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 [\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e]. 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.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eSome limitations should be noted in our study. We based our evaluation of executive functions a two-factor model (working memory and inhibition) for adolescents [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], cognitive flexibility also impacts the relationship between executive functions and empathy [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Additionally, we did not account for children's IQ scores, despite evidence suggesting their relevance to cognitive and affective empathy [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], externalizing disorders, executive functions, and empathy [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] 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.\u003c/p\u003e \u003cp\u003eFurthermore, 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 [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], 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 [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e], 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.\u003c/p\u003e \u003cp\u003eA cross-sectional study is another limitation of our study. Different results can be observed in studies involving empathy, executive functions, and different psychiatric diagnoses [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e, \u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e]. 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.\u003c/p\u003e \u003cp\u003eFinally, 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.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTo our knowledge, this is the first study to evaluate the relationship between internalizing and externalizing symptoms, executive functions (such as inhibition and working memory), and cognitive and affective empathy in a community sample of adolescents. By evaluating both symptom types separately, even in children with psychiatric symptoms, we achieved a detailed analysis of their interaction with empathy components.\u003c/p\u003e \u003cp\u003eOur findings are consistent with the literature that executive functions and cognitive empathy are more closely related than affective empathy [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Executive function deficits are developmental risk factors that can lead to emotion regulation difficulties and externalizing disorders due to inadequate top-down regulation of subcortical regions [\u003cspan additionalcitationids=\"CR88\" citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e]. This supports our argument that executive functions are linked to empathy, particularly in the context of internalizing symptoms.\u003c/p\u003e \u003cp\u003eThe negative relationship between externalizing symptoms and both cognitive and affective empathy in our study is consistent with previous clinical research [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. However, unlike some studies, we did not find significant positive associations between internalizing symptoms and affective empathy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e]. Our results showed a negative but non-significant relationship between internalizing symptoms and affective empathy, which are consistent with some other studies that found no significant linear relationship [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] or a quadratic relationship for cognitive empathy [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThis study was conducted with high-risk children who had not yet received a psychiatric diagnosis. The authors suggested that internalizing symptoms might impair social interpretation and empathy due to a self-focused state affecting social experiences and relationships [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e]. Similarly, our study found empathy deficits in children with psychiatric symptoms compared to those in the pilot study.\u003c/p\u003e \u003cp\u003eAdditionally, the higher number of children with externalizing symptoms in our sample may have influenced the observed relationships. Disorders like conduct disorder and ADHD have been shown to negatively relate to affective empathy [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e] The presence of children with comorbid internalizing and externalizing disorders may have also affected our results. Further studies examining the effects of such comorbidities, common in adolescents [\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e], will help clarify these relationships.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our sincere appreciation to all the participants who generously shared their time and provided valuable insights for this study. \u0026nbsp; We also extend our gratitude to the school principals for their support in facilitating the data collection process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors did not receive support from any organization for the submitted manuscript.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the permission obtained from the ethics committee of Toros University (2023/127). Written informed consent was obtained from a parent or legal guardian, followed by written assent from the participants.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBlakemore, S. J., \u0026amp; Choudhury, S. Development of the adolescent brain: Implications for executive function and social cognition. \u003cem\u003eJ. Child Psychol. Psychiatry\u003c/em\u003e. \u003cstrong\u003e47\u003c/strong\u003e(3‐4), 296-312 (2006).\u003c/li\u003e\n\u003cli\u003eGhasemian, A., \u0026amp; Venkatesh, G. K. 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M. Social anxiety symptoms in young children: Investigating the interplay of theory of mind and expressions of shyness. \u003cem\u003eJ. Abnorm. Child Psychol.\u003c/em\u003e\u003cstrong\u003e45\u003c/strong\u003e, 997-1011 (2017).\u003c/li\u003e\n\u003cli\u003eFinsaas, M. C., Bufferd, S. J., Dougherty, L. R., Carlson, G. A., \u0026amp; Klein, D. N. Preschool psychiatric disorders: Homotypic and heterotypic continuity through middle childhood and early adolescence. \u003cem\u003ePsychol. Med\u003c/em\u003e.\u003cstrong\u003e 48\u003c/strong\u003e(13), 2159-2168 (2018).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Empathy, executive functioning, internalization, externalization","lastPublishedDoi":"10.21203/rs.3.rs-4801384/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4801384/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePrevious studies have shown associations between internalizing and externalizing symptoms, executive functions, and empathy. However, the mechanisms that affect this relationship remain unclear. This study employed regression analysis to explore the predictive effect of internalizing and externalizing symptoms and executive functions on empathy.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eOur study consisted of three consecutive stages. In the first stage, we assessed 2150 adolescents\u0026rsquo; parents of 2150 adolescents aged 10\u0026ndash;12 years using the Strengths and Difficulties Questionnaire to determine which participants should be included in the subsequent stages. In the second stage, we conducted a pilot study with 50 participants to assess the validity of the assessment system and the six film scenes to be used in the following stage. Finally, in the third stage, we obtained the participants' state empathy, trait empathy, and executive functioning.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe regression analysis showed that working memory performance (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.261) and externalizing symptoms (\u003cem\u003eβ\u003c/em\u003e = -0.157) predicted cognitive empathy, but only externalizing symptoms predicted affective empathy (\u003cem\u003eβ\u003c/em\u003e = -0.193).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study highlights the effect of externalization on both cognitive and affective empathy and the effect of working memory on cognitive empathy. These findings may serve to inform psychological interventions to improve empathic abilities in early adolescence.\u003c/p\u003e","manuscriptTitle":"Relationships between Empathy, Executive Functions, and Internalizing and Externalizing Symptoms in Early Adolescents","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-02 13:40:19","doi":"10.21203/rs.3.rs-4801384/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-29T12:19:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-27T02:37:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-27T02:36:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2024-07-25T11:08:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"131ec3cb-54db-4a9c-b9ff-5283016fde09","owner":[],"postedDate":"September 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-02T17:22:00+00:00","versionOfRecord":{"articleIdentity":"rs-4801384","link":"https://doi.org/10.1186/s12888-024-06324-8","journal":{"identity":"bmc-psychiatry","isVorOnly":false,"title":"BMC Psychiatry"},"publishedOn":"2024-11-28 15:57:51","publishedOnDateReadable":"November 28th, 2024"},"versionCreatedAt":"2024-09-02 13:40:19","video":"","vorDoi":"10.1186/s12888-024-06324-8","vorDoiUrl":"https://doi.org/10.1186/s12888-024-06324-8","workflowStages":[]},"version":"v1","identity":"rs-4801384","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4801384","identity":"rs-4801384","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}