Teaching Children with Autism to Mind-Read

The Workbook

Julie A. Hadwin, Patricia Howlin, Simon Baron-Cohen

• Publisher: Wiley-Blackwell
• Year: 2014
• ISBN:
  9781118314869
• Edition: 1
• Topic: Éducation
• Subtopic: Difficultés d'apprentissage

This workbook expands upon the authors? Teaching Children with Autism to Mind-Read: A Practical Guide to present the most effective approaches, strategies, and practical guidelines to help alleviate social and communication problems in individuals with Autism Spectrum Disorders (ASD).

• Complements the best-selling Teaching Children with Autism to Mind-Read: A Practical Guide for use in practical settings
• Answers the need for more training of professionals in early interventions for children assessed with ASD called for by the National Plan for Autism
• Written by a team of experts in the field
• Covers issues such as how to interpret facial expressions; how to recognize feelings of anger, sadness, fear and happiness; how to perceive how feelings are affected by what happens and what is expected to happen; how to see things from another person?s perspective; and how to understand another person?s knowledge and beliefs

Chapter 1
Introduction

Introduction to Theory of Mind

Individuals with autism spectrum conditions (ASC) have difficulties in social interaction and communication, alongside repetitive and stereotyped behaviors and unusually narrow interests.1 Social interaction difficulties include indifference or aloofness towards other people, problems understanding and responding to social cues or displaying inappropriate social behavior. For example, individuals with ASC may display less eye contact and make fewer gestures when speaking with others. In addition, they may show atypical body posture or proximity when interacting (e.g., an awkward or unusual gait, or standing too close to another person or talking in too loud a voice). In these situations individuals with ASC often do not have a good enough understanding of the unspoken rules of conversation, or the social norms required to interact effectively with others.

Theory of mind

Effective social interaction requires an understanding of the mental states of others, including their beliefs, emotions, intentions and desires. Theory of mind (ToM) is a term used to encompass an individual's ability to understand mental states in order to make predictions about a person's behavior.2 A substantial body of research has shown that individuals with ASC show difficulties and delays in understanding the thoughts and feelings of other people and in demonstrating that people can have thoughts and feelings that differ from each other and their own.3

Understanding false beliefs

One key test of ToM, used many times in research, explores whether children and adults understand that other people can have a different belief to themselves, where this belief can sometimes be false. This level of understanding is referred to as first-order ToM. One method developed to assess ToM used by Simon Baron-Cohen and colleagues in the 1980s is the Sally-Anne task.4 The aim of this task is to test the age at which individuals understand that other people can hold false beliefs and that their behavior and emotions are related to these beliefs. In this task^* Sally puts an object in one location which is later moved to a different location by Anne, without Sally's knowledge. Typical children over 4 years old understand that Sally now has a false belief about the object's location: they recognize that Sally didn't see Anne move the object so she will think it is still in its original location. They therefore predict that Sally will look for the object in the location where she put it (even though it isn't there). By the age of 7 they also understand that Sally's desire and her false belief that she is about to find the object will lead her to feel happy, until she discovers that the object is missing, when she will feel sad.5

Almost all typically developing children show some understanding of false belief tasks by the age of 5.7 The change in thinking about mental states at this stage in development has led some researchers to argue that a conceptual change takes place between the ages of 2½ (the earliest age at which children pass such tests) and 5.8 The extent to which children show an understanding of false belief earlier or later in development may be a function of their social environment and language development, or perhaps their biology. Links between ToM and language ability have been found in several studies.9, 10 ToM tasks often require children to understand embedded sentences (e.g., Sally thinks that the ball is in the basket) and it is therefore not surprising that language ability is associated with passing these tasks. The direction of this relationship, however, is most likely a reciprocal one: good language skills enable children to interpret information about other people's mental states and beliefs. Conversely, ToM skills serve to facilitate the development of children's understanding of language by thinking about a speaker's intentions and what the listener needs to know.11

Other research has shown that a relatively early emergence of ToM can reflect a favorable learning environment. For example, children with one or more siblings are more likely to show an earlier understanding of false belief compared with those who have no siblings.12 In addition, increased parental sensitivity is associated with a better mental state understanding and more positive friendship interactions.13 Similarly, more advanced ToM tasks are better understood by adults who have more extensive social support networks14 and children who display better social skills.15 Taken together, these studies suggest that aspects of a child's environment can facilitate the development of ToM skills and they highlight the interconnectivity between ToM and the development of social skills.

Understanding false belief in individuals with ASC

In contrast to patterns seen in typical development, most children with ASC do not pass false belief tasks until late childhood. A typical error made by young children and children with ASC is that they attribute beliefs to others that reflect the actual situation, rather than what someone believes to be true. For example, they often predict that Sally will look in the location where Anne has moved the ball. In other words, they fail to understand that because Sally did not see the move, she won't know its current location. While many older children and adults with ASC eventually pass false belief and other ToM tasks, this is typically after a significant delay. For example, one study found that children with ASC start to show some success in passing false belief tasks when they reach a verbal mental age of around 8 and this ability continues to improve with increasing verbal ability.16 However, further studies have found that even when children with ASC can pass ToM tasks, they still display a characteristic lack of insight in their day-to-day lives.17, 18 This finding has led some researchers to argue that children with ASC who pass ToM tasks have developed compensatory learning strategies.19 The poor association between passing ToM tasks and the development of broader social skills has also been demonstrated in several studies. For example, individuals with ASC who were able to pass the Sally-Anne task failed to ascribe mental states or emotions to a pattern of moving geometric animations in the same way as their typically developing peers.20 Similarly, children with Asperger Syndrome who passed traditional ToM tasks did not show typical spontaneous anticipatory eye movements to the relevant locations in a false belief scenario.21

Technological advances over the last 15 years have allowed researchers to locate areas of the brain that are activated during ToM. Using brain scanning methods such as fMRI, PET or SPECT, typically developing individuals show activation in the medial prefrontal cortex, amygdala and temporal parietal areas of the brain.22, 23 In contrast, these brain regions are under-active in individuals with ASC when performing similar tasks, and instead the brain uses areas that are associated with general problem solving.24 These findings further support the idea of compensatory learning in ASC.

A developmental perspective

In recent years, researchers have adopted a developmental approach when trying to understand the acquisition of ToM. It is now recognized that ToM involves several skills that emerge across development and is not just indexed by passing false belief tasks. Studies have employed a wider range of tasks that draw on children's abilities to reason about mental states at different ages. In infancy and toddlerhood, for example, early social-based skill deficits in ASC often manifest in poor joint attention.25, 26 Joint attention is the ability to coordinate attention with others to objects and events in the environment, using either gaze or gesture or language. In typical development, joint attention (seen for example in gaze following or the pointing gesture) emerges between the ages of 9 and 14 months.27

Desires and beliefs

Further research has proposed that ToM does not emerge as a single cognitive process, but is made up of several interrelated skills including the ability to reason about other people's beliefs, intentions, knowledge, emotions and desires.28, 29 The ability to predict the desires of others emerges prior to the ability correctly to determine their beliefs.30–33 Accordingly, children understand that two people can want the same toy, before they understand that two people can hold different beliefs about the same toy. Following this, children also understand that two people can hold different beliefs about the same situation, before they come to an understanding that someone can hold a belief about that situation that is false.

Looking beyond false belief understanding, one area of research has considered the development of ToM skills beyond early childhood. Francesca Happé developed a set of “Strange Stories” to assess more advanced ToM skills.34 These stories rely on a person's understanding of the non-literal use of language as depicted in communicative intentions around concepts such as irony and sarcasm. For example, in the sarcasm scenario the main character comments “Lovely day for a picnic!” (when it is raining outside). The reader is then asked if the person in the story has said something true, and why they said it. Both typically developing children and adults with high-functioning autism who show no difficulty in passing standard ToM false belief tasks struggle to interpret this type of scenario. Often, it is not until late childhood that children show some understanding of the non-literal use of language in these stories.35–37

This broad research agenda stemmed from the development of what has been termed second-order ToM tasks (“thinking about thinking”). These tasks involve reading a story with several characters, where children or adults are asked to comment on what one character thinks another character believes. It is generally accepted that second-order ToM develops at around 6 or 7 years of age.38 Most typically developing adults show difficulties thinking through scenarios that require understanding beyond third-order ToM tasks. In a recent study, 10- and 11-year-old children were tested up to fourth level ToM.15 At this age, children passed first- and second-order ToM tasks without any difficulties, but they made significantly more errors in third-order stories, and were equally likely to be correct as incorrect on fourth-order tasks. This study highlights that ToM continues to develop and improve through late childhood and into adulthood.

Teaching ToM to Children with Autism

Since the original publication of Teaching Mindreading,39 theoretical and empirical work has continued to focus on ToM as a factor that underpins the social and interaction difficulties evident in individuals with ASC. A growing number of studies have explored teaching ToM to children and adults with ASC, with most studies focusing on children in late childhood and adolescence.

Studies aiming to teach children with ASC to understand mental states have generally found that children are able to learn to pass ToM tasks and to transfer their knowledge to conceptually similar tasks that have not been directly taught.40–42 Some studies have found evidence of generalization to novel ToM tasks;43, 44 although demonstrating that children can use new skills to pass novel ToM tasks or in real-life situations has often proven to be problematic.45

This lack of generalization has raised questions about what children learn during ToM teaching; do they learn about mental states or have they simply acquired “...