Thought Bubbles help children with autism acquire an alternative to a theory of mind

Henry M. Wellman, Simon Baron-Cohen, Robert Caswell, Juan Carlos Gomez, John Swettenham, Eleanor Toye, Kristin Lagattuta Autism, Vol 6(4) 343-363.

Children with autism have specific difficulties understanding complex mental states like thought, belief, and false belief and their effects on behaviour. Such children benefit from focused teaching, where beliefs are likened to photographs-in-the-head. Here two studies, one with seven participants and one with ten, tested a picture-in-the-head strategy for dealing with thoughts and behaviour by teaching children with autism about cartoon thought-bubbles as a device for representing such mental states. The prosthetic device led children with autism to pass not only false belief tests, but also related theory of mind tests. These results confirm earlier findings of the efficacy of picture-in-the-head teaching about mental states, but go further in showing that thought-bubble training more easily extends to children's understanding of thoughts (not just behaviour) and to enhanced performance on several transfer tasks. Thought-bubbles provide a theoretically interesting as well as an especially easy and effective teaching technique.

The theory of mind hypothesis for autism proposes that a central cognitive deficit for individuals with autism is an impairment in using mental state concepts. Mental state concepts such as a person's beliefs, knowledge, desires, and intentions, ordinarily allow us to understand our own and other's lives ('She doesn't know the song'), to predict behaviour ('She'll sing the wrong tune'), to interact socially ('To make her happy I'll choose a different song'), and to communicate ('She doesn't know that song, I'd better tell her the words'). Difficulties in understanding and using mental state concepts may therefore underlie the difficulties in social interaction and communication in autism. Most children with autism with mental ages well beyond 4 years have difficulties with tasks testing understanding of emotions, knowledge and ignorance, deception, and the mental-physical distinction, although these tasks are normally solved by 3- and 4-year-olds. The theory of mind deficit for autism has inspired possible training interventions for children with autism.

To overcome this problem, two recent studies have attempted to teach children with autism a more conceptually intriguing, picture-in-the-head strategy, to aid an understanding of mental states. Swettenham et al. and McGregor et al. al. both used training sessions where photographs were slotted into a manikin's head or a doll's head and children were told, 'When a person looks at something, they make a sort of a picture in their head'. Thoughts, including false thoughts, were thus portrayed as actual pictures inside a head.

In the present study we extend a general picture-in-the-head approach using a very different pictorial analogy: thought-bubbles. Thought-bubbles arguably provide a particularly natural or effective way of depicting thoughts pictorially, one that could come to aid autistic individuals reasoning about people, behaviour, and mental states. Such a strategy should provide a device for thinking about thoughts, and to be most effective should be based on cognitive abilities or skills known to be intact in individuals with autism.

The theoretical rationale for exploring a picture-in-the-head strategy receives some indirect, empirical support from a study by Hulburt et al. They elicited reports of inner experience (sampled during everyday activities) from three individuals with Asperger's Syndrome. These individuals consistently described only their perceptions and actions, devoid of thoughts, emotions, or inner speech. To the extent that they described inner experiences at all, however, they described them solely in terms of pictures in their head. Typical controls described a complex mixture of inner speech, emotional reactions, mental images, and pure thought.

Thought-bubbles are somewhat naturally occurring in that they, and relatedley speech-bubbles, appear in comics, cartoons, and sometimes in children's books. Moreover, 3-and 4- year-old normally developing children easily understand thought-bubbles as depictions of 'what the person is thinking', even in the case of mistaken thoughts or two people having different thoughts about exactly the same object.

False belief tasks come in at least two different forms. One, as in the Sally-Anne task, focuses on false beliefs created by a change of location. A second, captured in classic smarties tasks concerns beliefs about unexpected contents (a Smarties candy box that is opened to reveal pencils, not candy in it).

We do not want to give the false impression that thought-bubble instruction works effectively or easily with all children with autism, or even all relatively able children with autism of the sort we worked with. Several of the children we worked with learned very little. For several others, as noted, progress required creative tailoring to the child's skills, preoccupations, and limits (as well as teaching persistence).

Advanced Theory of Mind in High-Functioning Adults with Autism

Twenty-four high-functioning adults with autism (16 men) who passed a first-order theory-of-mind task and 24 nonautistic adults (10 men) attributed mental states to recordings of various verbal intonations and to photos of people’s eyes to assess advanced theory of mind. Participants with autism performed significantly worse than nonautistic participants on both tasks. Thus, the previously described inattention to others’ eyes exhibited by adults with autism is not solely responsible for their inability to attribute mental states from eyes, as they also did not correctly attribute mental states from voices. These findings support the view that a core deficit for people with autism lies in their theory of mind, that is, their inability to attribute mental states to others.

 

A New Advanced Test of Theory of Mind: evidence from children and adolescents with Asperger's Syndrome

Nils Kaland, Annette Meller-Nielsen, Kirsten Callesen, Erik Lykke Mortensen, Dorte Gottlieb and Lars Smith, Journal of Child Psychology and Psychiatry 43:4 (2002), pp 517-528.

The aim of the present study was to assess the ability of children and adolescents with Asperger’s Syndrome (AS) (N = 21) to infer physical versus mental states on a new ‘advanced’ test of theory-of-mind - Stories from Everyday Life. The participants in the AS group were of normal intelligence and were compared with an age-matched control group (N=20) of normally developing children and adolescents. The test materials comprised 26 short stories or 13 pairs of different types of stories. This contextually complex theory-of-mind battery aimed to record the participant’s ability to make inferences about physical as well as mental states. The first part of each story described a physical or mechanical event, and a test question then tested the participant’s ability to make an inference about a physical state. The last part of the stories contained two questions, testing the ability to infer a mental state from the story context, e.g., understanding social communication such as a lie, white lie, figure of speech, misunderstanding, double bluff, irony, persuasion, contrary emotions, forgetting, jealousy, intentions, empathy, and social blunders. The participant’s reaction time and number of prompt questions were also recorded. The participants in the AS group showed significantly more problems attributing mental state inferences relative to the control group. They performed considerably better on tasks involving a physical state, but still did less well than the controls. They had a tendency to interpret behaviour and utterances literally, without regard to context, and to choose a physical explanation when a mental state answer was more appropriate. They also needed significantly more prompt questions and used significantly more time than the controls to solve the tasks, especially those involving mental state inference.

This study supports earlier findings that individuals with AS/HFA have difficulties attributing mental states in context, but seem to have significantly fewer difficulties inferring physical states. The fact that the clinical group also used significant longer reaction time and needed significantly more prompt questions to solve the tasks relative to the control group may also be related to their problems in understanding mental states. However, the possibility remains that these difficulties could represent a separate factor - or a distinct cognitive style - suggesting that at least some individuals with AS may be generally slow in solving cognitive tasks.

As mentioned above, few previous studies have collected data on speed of problem solving on theory-of-mind tasks. The current recording of reaction times showed that many of the AS participants were slow and longwinded in the test situation and significantly slower than the controls, especially on mental inference performance. Hermelin and O’Connor (1985), who invoked the concept of ‘logico-affective’ states, have argued that some individuals with autistic spectrum disorders are able to use cognitive mechanisms to deal with problems that are usually dealt with by affective processes. Since such problems are usually encountered in the realm of social interactions, the use of cognitive rather than effective processes could, as Bowler (1992) suggests, result in a slowing of responses, and a disruption of the subtle timing of social interactions, thereby making the person seem odd to other people.

This view of autistic social impairment fits well with clinical accounts, and echoes Burner and Feldman’s (1993) description of interactions of individuals with AS. These interactions are likened to conversing with someone who is calculating his next move, or with someone who is working out a complicated maths problem.

Theory of Mind and Self-Consciousness: What Is It Like to Be Autistic?

By Frith, U., and Happe, F., (1999), Mind and Language, Vol. 14., No. 1, pp 1-22.

Autism provides a model for exploring the nature of self-consciousness: self-consciousness requires the ability to reflect on mental states, and autism is a disorder with a specific impairment in the neurocognitive mechanism underlying this ability. Experimental studies of normal and abnormal development suggest that the abilities to attribute mental states to self and to others are closely related. Thus inability to pass standard ‘theory of mind’ tests, which refer to other’s false beliefs, may imply lack of self-consciousness. Individuals who persistently fail these tests may, in the extreme, be unable to reflect on their intentions or to anticipate their own actions. In contrast, individuals with high-functioning autism or Asperger syndrome often possess late-acquired, explicit theory of mind, which appears to be the result of effortful learning. An experimental study with three people with Asperger syndrome suggested that level of performance on standard theory of mind tasks was strongly related to the ability to engage in introspection. Qualitative differences in the introspections of high-functioning people with autism are also reflected in autobiographical accounts which may give a glimpse of what it is like to be autistic.