Wednesday, September 6, 2017

Autism and Theory of Mind (ToM)

What is Theory of Mind?
Empathizing; Mentalizing; Mindreading; Perspective taking
The ability to attribute mental states such as thoughts, desires, knowledge, and intentions to self and others, and to make sense of and predict another person’s behavior.
ToM is a cognitive (attribution) component of empathy; the ability to identify cues that indicate the thoughts and feelings of others and “to put oneself into another person’s shoes.” It is also referred to as “mentalizing,” “mindreading,” and “perspective taking.” The ability to reflect on one’s own and other people’s minds (beliefs, desires, intentions, imagination and emotions) allows us to interact effectively with others in the social world. Most typical individuals are able to mindread relatively easily and intuitively. For example, we can read a person’s facial expression and body language, and tone of voice and recognize his or her thoughts and feelings, and the likely course of behavior. In other words, we interpret, predict, and participate in social interaction automatically, and for the most part, instinctively. This attribution of mental states is a fundamental component of social interaction and communication. A deficit in ToM results in an inability to appreciate other people’s emotions and thoughts, and to make sense of or predict another’s actions. As a consequence, the person with impaired ToM is said to have a form of “mindblindness” or a delay in cognitive empathizing ability.
Autism and ToM
The concept of ToM has been widely studied over the past two decades and used to explain the development of social cognition and the core social deficits of developmental disorders such as autism. The understanding of other people’s mental states develops early in life and becomes more complex with advancing age. Research suggests that typically developing children, in contrast to those with autism, develop a set of skills which enable them to comprehend and respond to other people’s mental states and feelings. For example, children can understand relationships between mental states by 3 years of age. By age four, they can understand that people can hold false beliefs (deception). Typical children at age seven begin to understand what not to say to avoid offending others. A typical 9 year old can interpret another person’s facial expressions and figure out what they are thinking or feeling. 

It is a delay or deficit in the process of cognitive empathizing or ToM that has the potential to explain the lack of pretend play and the core social and communication problems diagnostic of children with autism. The empathizing dimension has been broadened to include an affective (emotional) component and a second factor termed systemizing to explain the non-social areas of strength often demonstrated by individuals with autism spectrum conditions. Children with ToM challenges frequently experience academic, behavioral, and emotional problems related to their social skills deficits. Impairments in social reciprocity and communication are one of the defining characteristics of autism spectrum disorder. Consequently, interventions focusing on social adaptive skills are critically important to the treatment of this group of children. While the research on the effectiveness of social skills intervention is still in the formative stage, several programs have been developed to promote prosocial behavior and expand ToM abilities among children with autism spectrum disorder. They include: social stories, computer programs such as Mind Reading: The Interactive Guide to Emotions and The Transporters; ToM teaching programs; and social skills programming.
Key References and Further Reading
Baron-Cohen, S. (1991). The theory of mind deficit in autism: how specific is it? British Journal of Developmental Psychology, 9. 301-314.
Baron-Cohen, S., Jolliffe, T., Mortimore, C., & Robertson, M. (1997). Another advanced test of theory of mind: evidence from very high functioning adults with autism or Asperger Syndrome. Journal of Child Psychology and Psychiatry, 38. 813-822.
Baron-Cohen, S., Ring, H. A., Bullmore, E. T., Wheelwright, S., Ashwin, C., & Williams, S. C. R. (2000). The amygdala theory of autism. Neuroscience & Biobehavioral Reviews, 24(3), 355-364.
Baron-Cohen, S., & Swettenham, J. (1997). Theory of mind in autism: Its relationship to executive function and central coherence. Handbook of autism and pervasive developmental disorders, 880-893.
Baron-Cohen, S. (2000). Theory of mind in autism: A fifteen year review. In S. Baron-Cohen, H. TagerFlusberg, & D. J. Cohen (Eds.), Understanding other minds: Perspectives from developmental cognitive neuroscience (pp. 3–20). New York: Oxford University Press
Fletcher-Watson, S, McConnell, F, Manola, E & McConachie, H 2014, 'Interventions based on the Theory of Mind cognitive model for autism spectrum disorder (ASD)' Cochrane database of systematic reviews. DOI: 10.1002/14651858.CD008785.p
Begeer S. Theory of mind interventions can be effective in treating autism, although long-term success remains unproven Evidence-Based Mental Health 2014;17:120.
Fletcher-Watson S, McConnell F, Manola E, McConachie H. Interventions based on the Theory of Mind cognitive model for autism spectrum disorder (ASD). Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No.: CD008785. DOI: 10.1002/14651858.CD008785.pub2
Gray, C. A. (1998). Social stories and comic strip conversations with students with Asperger Syndrome and high-functioning Autism. In E. Schopler, G. B. Mesibov, & L. J. Kunce (Eds.), Asperger syndrome or high functioning autism? (pp. 167-194). NY: Plenum Press.
Holopainen, A., de Veld, D.M.J., Hoddenbach, E. et al. (2018). Does Theory of Mind Training Enhance Empathy in Autism? Journal of Autism Developmental Disorders.
Hutchins, T., & Prelock, P. A. (2008). Supporting theory of mind development: Considerations and recommendations for professionals providing services to individuals with ASD. Topics in Language Disorders, 28 (4), 340-364.
O’Brien, K., Slaughter, V. & Peterson, C.C. (2011). Sibling influences on theory of mind development for children with ASD. J Child Psychology & Psychiatry, 52(6), 713-719.
O’Hare, A.E., Bremner, L., Nash, M., Happe, F., Pettigrew, L.M. (2009). A clinical assessment tool for advanced theory of mind performance in 5 to 12 year olds. JADD, 39(6), 916-928.
Sprung, M. (2010). Clinically relevant measures of children’s theory of mind and knowledge about thinking: Non-standard and advanced measures. Child and Adolescent Mental Health, 15(4), 204-216.
Tager-Flusberg, H. (2001). A reexamination of the theory of mind hypothesis of Autism. In J. A. Burack, T. Charman., N. Yirmiya., & P. R. Zelazo (Eds.), The development of autism: Perspectives from theory and research (pp.173-193). Mahwah, NJ: Lawrence Erlbaum.
Wellman, H. M., Baron-Cohen, S., Caswell, R., Gomez, J. C., Swettenham, J., Toye, E., & Lagattuta, K. (2002). Thought-bubbles help children with autism acquire an alternative to a theory of mind. Autism, 6(4), 343-363.
Wilkinson, L. A. (2011). Mindblindness in Encyclopedia of Child Behavior and Development, Part 13, 955-956, DOI: 10.1007/978-0-387-79061-9_1795
Wilkinson L. (2012). DSM-5: Rethinking Asperger’s Disorder. Autism 2:e113 10.4172/2165-7890.1000e113 
Wilkinson, L. A. (2015). Overcoming Anxiety on the Autism Spectrum: A Self-Help Guide Using CBTLondon and Philadelphia: Jessica Kingsley Publishers.
Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. Jessica Kingsley Publishers. London and Philadelphia.
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, chartered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a best-selling text in the APA School Psychology Book Series,  Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

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