Children who survive neonatal open-heart surgery are expected to attain normal intellectual outcomes, but over time unexpected problems in academic and social attainments occur and have attracted increasing attention. Calderon et al. present further evidence as to what might underpin these difficulties through their exploration of social cognition in children undergoing early surgery for transposition of the great arteries. Although the neuropsychology of social cognition impairments is quite challenging to assimilate, the authors can be commended on their clear account of what the children were actually requested to do, the strength of their comparison group, and their balanced discussion of the limitations but importance of their findings.
The methodologies for measurement of social understanding owe their development to the demonstration of their importance in the everyday impairments seen in autism spectrum disorders. However, children surviving neonatal open-heart surgery for transposition of the great arteries join the many other groups of children who are also now understood to have greater risks of social cognition deficits and everyday peer interactional difficulties: the preterm survivor, the hearing impaired, and those affected with attention-defiicit–hyperactivity disorder or specific speech and language impairment.
Calderon et al. approach the assessment of social cognition in these children with transposition of the great arteries by measuring facial emotion recognition (which was relatively well maintained), emotion comprehension, and so-called ‘false belief’ understanding. All tasks require the child to impute the thoughts and feelings of others within experimental paradigms that always rely to some extent on language. Language comprehension was factored in and modified some of the findings but the significant impairment on complex affective mental state understanding remained. Even amongst children with typical development there is a wide range of function in false belief tasks, and those with faster acquisition of language skills make greater progress.
These outcomes for children despite having had very early intervention of their cyanotic congenital heart disease are concerning. What do they mean for long-term prognosis and everyday social interaction? We do not know and Calderon et al. agree that future studies should combine these measures of social cognition with ecological reports of everyday social interaction. There is an indication from Schaefer et al.'s  2013 cohort of children with heterogeneous congenital heart disease that this type of reporting does indeed indicate such real-life issues captured through instruments such as the pro-social scale of the Strengths and Difficulties Questionnaire which were employed in an adolescent study.
Calderon et al.'s study does highlight possible protective factors: antenatal diagnosis, early surgery, and the presence of a ventricular septal defect. Are they all operating through remediating the length of time the child experiences cyanosis and would this lend itself to biomedical markers such as imaging of the white matter?
These questions as to what the components of the social cognition difficulties are, how are they underpinned by language development, and whether they can be prevented in congenital heart disease remain crucial, but even by demonstrating their existence there is scope to support the child. This type of difficulty can have an impact across the curriculum affecting skills such as conjecturing and understanding complex language such as metaphor, sarcasm, ‘white lies’, and persuasion. Might one suggest that Calderon et al. may be describing an important component of adaptive behaviour, which can be expressed as ‘the performance of the daily activities required for personal and social sufficiency, and defined by the expectations or standards of other people’? Such an approach might allow early questioning as to why a child who has undergone neonatal congenital heart disease surgery is unexpectedly failing socially and academically despite being of normal intellect, and encourage social cognition screening as Calderon et al. suggest in the summing up of their paper.