Can children with autism develop a theory of mind (ToM)?

Introduction

A Theory of Mind (ToM) can be defined as the way in which children aged 3-to-4 years begin to develop a theory about their own and other people's mental states, which include beliefs, intentions, knowledge and desires (Baron-Cohen, 1995). It is argued that humans have an innate predisposition to make inferences about their own and other people's behaviour in order to predict and understand behaviour and that these mental processes have evolved because of the generally social and co-operative nature of life (Baron-Cohen, 1995). Mitchell and Lewis (1994) further argue that humans frequently attempt to manipulate the behaviour of others and one way of achieving this to instil a false belief, which can be achieved through the use of deception. The false belief task has become the classic test of determining whether young children have developed a ToM. However, research suggests that children with autistic spectrum disorders (ASD) are unable to develop a ToM as they have difficulty understanding the concept of a false belief. The following essay will explore research that has investigated children with ASD and the question of whether they are able to develop a ToM is supported or refuted.

Methodology for Determining a ToM

The methodology used to establish whether a ToM has developed during early childhood is known as a false belief task (FBT). To pass a FBT, children are required to give the correct answer about a belief held by another individual and the ability to do this occurs in typically developing children at about the age of 4 years. There have been a number of variations of the FBT which follow a similar format involving young children demonstrating an understanding that another person can have an incorrect belief in comparison to their own belief. Wimmer and Perner (1983) developed the classic FBT, the unexpected transfer task, in which children are asked to infer the beliefs of Maxi regarding his chocolate bar. Maxi (a doll or puppet) puts his chocolate in one cupboard and then goes out of the room. While he is away his mother moves the chocolate bar to a different cupboard and the children are asked which cupboard Maxi will go to for his chocolate when he returns.  The results showed that older children (92% aged 6- to 7-years) said that Maxi would look in the cupboard where he left his chocolate bar, whereas 58% of children aged 4- to 5-years said he would look in the cupboard that his mother had moved the chocolate bar to (Wimmer and Perner, 1983). Variations on the task include the Sally-Anne task developed by Baron-Cohen, Leslie, and Frith (1985) in which Sally hides her ball and, when she is not looking, Anne moves the ball to a basket. The children are asked where Sally will look for her ball and most children aged 4 understand Sally will have a false belief about where her ball is. Another FBT involves a deceptive box in which children are shown a box covered with pictures of Smarties. When the box is opened there are pencils inside, not Smarties. Children aged 40 months were asked what their friend would think was inside the box, 70% said pencils, whereas 50% of children who were almost 4 years old said Smarties (Perner, Leekham and Wimmer, 1987). The findings from FBTs are consistent and appear to demonstrate that around the age of 4 years typically developing children go through a conceptual change in being able to articulate and form a representation theory of other people's mental states (Surian and Leslie, 1999).

However, according to Mitchell and Lewis (1994) the wording used in false belief tasks may lead to misunderstandings by typically developing children younger than 4-years. Other factors can also contribute to some children passing a FBT. Earlier ability, for example, language development, has been considered an important factor (Fisch, 2013) and those children with older siblings and children who participate in fantasy play (Wellman, 2014).

Autistic Spectrum Disorder (ASD)

The American Psychiatric Association, in its Diagnostic and Statistical Manual of Mental Disorders, 5th edition defines ASD as a condition where there are 'persistent deficits in social communication and social interaction' this involves impairment in verbal and non-verbal communication together with repetitive and stereotypical patterns of behaviours and interests (DSM-V, APA, 2013, p.50). ASD is a spectrum disorder and can range from autism with severe impairments to Asperger's Syndrome which means the individual is high functioning and has a typical IQ (Adams, 2013). It is suggested by Senju, Southgate, White, and Frith (2009) that high functioning individuals with Asperger's Syndrome are more likely to develop a conceptual understanding of a ToM in comparison to those with classic autism. However, according to Wellman (2014) most adolescents and adults with ASD perform poorly on FBTs.

Wellman (2014) argues that children with ASD have delayed cognitive abilities in areas such as language development and therefore this, together with their social impairments, prevent them from developing a ToM. Using an unexpected transfer FBT with children with ASD older than 4 years Baron-Cohen et al. (1985) found that they were not able to successfully complete the task. As children with ASD have several cognitive impairments it was proposed that the failure to pass the FBT may be related to learning difficulties. However, when the children with ASD were compared with a control group of typically developing children and a group of children with Down's syndrome, learning difficulties were not found to affect the successful performance for the children with Down's (Baron-Cohen et al.1985). Many other studies have found similar results with different groups of children compared to typically developing children that appears to suggest there is a cognitive impairment in children with ASD in developing a ToM (Baron-Cohen, 1995).  Surian and Leslie (1999) further suggest that the findings from these studies suggest there are specialised neurocognitive mechanisms that support the development of a ToM.

Surian and Leslie (1999) used the Sally-Anne FBT and compared children and adolescents with ASD and mental ages of around 4-years, with a group of typically developing 3-year-old children. As predicted by Surian and Leslie, all the children in both groups failed to pass the FBT. However, even with instruction the children with ASD did not improve and remained unable to pass the FBT, although the 3-year old typically developing children showed improvement. The research identifies cognitive limitations in the typically developing children at age 3 which affects their performance, whereas the children with ASD appeared to be caused by a 'deeper meta-representational impairment' (Surian and Leslie, 1999, p.141). The study shows that although both groups of children (those aged under 4 years and those with ASD) typically fail the FBT, the reasons for the failure are different. The 3-year old children could pass the FBT with prompts and guidance, however, this was not the case for the children with ASD.[AJ1] It is concluded by Surian and Leslie (1999, p.153) that typically 'developing 3-year-old children have intact conceptual competence and limited processing capabilities, whereas children with autism have sufficient processing resources but limited conceptual competence'.

Children with ASD may respond more successfully to a FBT if other mediums such as drawing are used. In a study that compared typically developing children (aged 4-years) with a group of children who had learnt signing language late in childhood and a group of children with ASD (aged 6-to-13 years), a standard FBT and a drawing FBT were used (Peterson, 2002). It was found that the late signing children and the children with ASD had lower scores than the typically developing children in the standard FBT. However, in the drawing FBT the late signing children and the children with ASD had higher scores than the typically developing children. The findings suggest that children with ASD (as well as the late signing children) have some understanding of the conceptual nature of an FBT but appear to be unable to express it in a standard, verbal way. The study supports the role of language in the development of a ToM as the profoundly deaf children who had not learnt signing until relatively late, had a three-year delay in developing a ToM (Peterson, 2002). It is also suggested by Peterson (2002, p.1457) that drawing may be a better way for children with ASD to communicate as they may have difficulties recognising 'a link between what people say and what they think because their minds are organised in a more pictorial manner around visual images'.

Neurological Evidence regarding the ToM

Fisch (2013) argues that technological developments in neuroimaging appear to suggest that a neurocognitive explanation is more appropriate than other explanations for the social and cognitive impairment in ASD. This perspective is supported by Wellman (2014) who reports that when neuroimaging techniques are used the medial prefrontal cortex and right temporoparietal junction are the predominant areas activated during ToM tasks such as social reasoning (Wellman, 2014). In a longitudinal study undertaken over a 5-year period by White, Frith, Rellecke, Al Noor and Gilbert (2014) typically developing children were compared with children with ASD. Using functional magnetic resonance imaging (fMRI) atypical activity was found in the children with ASD and that 'there is a neurophysiological abnormality that persists despite improvements over time, despite individual differences in performance, and is present even in mildly impaired ASD adolescents' (White et al. 2014, p.23).

Can a ToM be Taught?

Evidence from the research undertaken by Surian and Leslie (1999) and discussed previously appears to suggest that despite prompts and guidance, passing an FBT did not improve in children with ASD. Swettenham (1996) attempted to teach a ToM using a computerised version of the Sally-Anne task which may be more appropriate for children with ASD. This is because children with ASD have problems communicating with other people and respond well to computers as there is no social interactions involved and they can work at their own pace. In the study there were three groups; children with ASD (mean age 10-years), typically developing children (mean age 3.5-years) and children with Down's syndrome (mean age 11-years). It was found that all three groups passed the Sally-Anne task after instruction. However, although the typically developing children and the children with Down's syndrome were able to generalise the finding to other similar tasks, this was not the case for the children with ASD. Swettenham (1996) suggests that the children with ASD developed a different type of strategy in order to pass the task but did not have any understanding of the conceptual principles of the FBT.

However, Begeer et al. (2011) also investigated the effectiveness of ToM training children with autism using a randomised controlled trial in which children with 40 high functioning ASD children with normal intelligence levels, aged between 8- and 13-years who were compared with a control group of typically developing children. It was found that children with ASD improved in their conceptual ToM skills, but not in their understanding, self-reported empathic skills or parent-reported social behaviour.

Conclusion

There appears to be considerable evidence in the many studies undertaken in the 1980s and 1990s that suggest that children with ASD are unable to develop a ToM and do not understand that other people can hold a false belief. However, there appear to be some inconsistencies in the research, for example Peterson (2002) found that children with ASD were more successful passing an FBT using drawing rather than verbal responses. Swettenham (1996) [AJ2]however, found that while children with ASD could pass an FBT presented on a computer they were using a different type of strategy and there was little understanding of the conceptual principles of a ToM. Children with ASD, who experience language delay as well as social impairments may have greater difficulty understanding a FBT (Wellman, 2014). However, one problem with early research into ToM is the methodology used which relies heavily on just one indication of whether a child has acquired a ToM, which is the FBT, even though there are several variations of the task. More recent research has used neuroimaging techniques (e.g. White et al. 2014; Wellman, 2014) which appears to suggest damage to the areas involved in ToM activity.

References

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White, S.J., Frith, U., Rellecke, J., Al-Noor, Z. and Gilbert, S.J.  (2014). Autistic adolescents show atypical activation of the brains mentalizing system even without a prior history of mentalizing problems.  Neuropsychologia, 56, 17-25.

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